Provider Demographics
NPI:1073747895
Name:TRACEY, LESLIE (LCPC)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:TRACEY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:338 WHISPERING WILLOW WAY
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:MT
Mailing Address - Zip Code:59828-9316
Mailing Address - Country:US
Mailing Address - Phone:406-370-5439
Mailing Address - Fax:
Practice Address - Street 1:109 N 4TH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-2401
Practice Address - Country:US
Practice Address - Phone:406-370-5439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1400101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1477745370Medicaid