Provider Demographics
NPI:1114080025
Name:AGNEW, TRACI (MA, MHP)
Entity Type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:
Last Name:AGNEW
Suffix:
Gender:F
Credentials:MA, MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3998 WYNDAM HILL DR
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6483
Mailing Address - Country:US
Mailing Address - Phone:770-271-4933
Mailing Address - Fax:
Practice Address - Street 1:175 GWINNETT DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-8444
Practice Address - Country:US
Practice Address - Phone:770-339-5070
Practice Address - Fax:678-377-3770
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health