Provider Demographics
NPI:1093947657
Name:LEWIS, TRACY MARIE (LCSW)
Entity Type:Individual
Prefix:MISS
First Name:TRACY
Middle Name:MARIE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:TRACY
Other - Middle Name:MARIE
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:925 SULLIVAN AVE
Mailing Address - Street 2:UNIT 2
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-2025
Mailing Address - Country:US
Mailing Address - Phone:860-432-7771
Mailing Address - Fax:860-432-7774
Practice Address - Street 1:925 SULLIVAN AVE
Practice Address - Street 2:UNIT 2
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-2025
Practice Address - Country:US
Practice Address - Phone:860-432-7771
Practice Address - Fax:860-432-7774
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-17
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00069941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008013935Medicaid