Provider Demographics
NPI:1114460268
Name:DANIELS, TRACY (CSAC, LPC, ICS)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:DANIELS
Suffix:
Gender:F
Credentials:CSAC, LPC, ICS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5735 DURAND AVE STE A
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-5011
Mailing Address - Country:US
Mailing Address - Phone:262-598-1392
Mailing Address - Fax:
Practice Address - Street 1:1717 TAYLOR AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-2405
Practice Address - Country:US
Practice Address - Phone:262-638-6674
Practice Address - Fax:262-638-6540
Is Sole Proprietor?:No
Enumeration Date:2016-11-22
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11389101YA0400X
WI8036101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI10062879Medicaid