Provider Demographics
NPI:1114124211
Name:HENDEL, TRACY ANN
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:ANN
Last Name:HENDEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 S PINE ST
Mailing Address - Street 2:
Mailing Address - City:WALHALLA
Mailing Address - State:SC
Mailing Address - Zip Code:29691-2146
Mailing Address - Country:US
Mailing Address - Phone:864-886-4400
Mailing Address - Fax:
Practice Address - Street 1:414 S PINE ST
Practice Address - Street 2:
Practice Address - City:WALHALLA
Practice Address - State:SC
Practice Address - Zip Code:29691-2146
Practice Address - Country:US
Practice Address - Phone:864-886-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
SC4564103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health