Provider Demographics
NPI:1114066552
Name:TREACY, TRACY (MS,, LPC, CADC-1)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:TREACY
Suffix:
Gender:F
Credentials:MS,, LPC, CADC-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2568 N DR MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-2710
Mailing Address - Country:US
Mailing Address - Phone:414-265-0300
Mailing Address - Fax:414-265-0200
Practice Address - Street 1:2568 N DR MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-2710
Practice Address - Country:US
Practice Address - Phone:414-265-0300
Practice Address - Fax:414-265-0200
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2555-125101Y00000X, 101YM0800X
WI2555125101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2161OtherPROVIDER # WISER CHOICE
WI43585300Medicaid