Provider Demographics
NPI:1073824389
Name:NUSSBAUMER, TRACEY LYNNE
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:LYNNE
Last Name:NUSSBAUMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:LYNNE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:518 BALLAD LANE
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116
Mailing Address - Country:US
Mailing Address - Phone:503-706-8028
Mailing Address - Fax:
Practice Address - Street 1:232 N.E. LINCOLN
Practice Address - Street 2:SUITE E
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124
Practice Address - Country:US
Practice Address - Phone:503-706-8028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-01
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA603027102101YM0800X
WALH60173003101YM0800X
ORC2821101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health