Provider Demographics
NPI:1083015309
Name:MOWLES, TRACY (LPC)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:
Last Name:MOWLES
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5673 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24012-1119
Mailing Address - Country:US
Mailing Address - Phone:540-523-8080
Mailing Address - Fax:
Practice Address - Street 1:5673 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-1119
Practice Address - Country:US
Practice Address - Phone:540-523-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-05
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701005926101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1437137734Medicaid