Provider Demographics
NPI:1124359682
Name:ELLMAN, TRACY D (LCSW)
Entity Type:Individual
Prefix:MR
First Name:TRACY
Middle Name:D
Last Name:ELLMAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 C ST NE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354-6316
Mailing Address - Country:US
Mailing Address - Phone:918-540-1563
Mailing Address - Fax:918-542-7778
Practice Address - Street 1:30 C ST NE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-6316
Practice Address - Country:US
Practice Address - Phone:918-540-1563
Practice Address - Fax:918-542-7778
Is Sole Proprietor?:No
Enumeration Date:2010-01-23
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
OK47241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100732380CMedicaid