Provider Demographics
NPI:1124534565
Name:OWEN, TRACIE
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:OWEN
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 1:1219 S ROCKFORD RD
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-3650
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 W MAIN ST STE 210
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-6320
Practice Address - Country:US
Practice Address - Phone:580-224-2929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-21
Last Update Date:2017-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor