Provider Demographics
NPI:1114552932
Name:POWELL, TRACIE LYNNE
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:LYNNE
Last Name:POWELL
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 1:80 WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45215-1430
Mailing Address - Country:US
Mailing Address - Phone:513-371-6003
Mailing Address - Fax:
Practice Address - Street 1:11156 CANAL RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45241-5815
Practice Address - Country:US
Practice Address - Phone:513-772-6166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-12
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator