Provider Demographics
NPI:1144009879
Name:DOUTRE, TRACI R (NBC-HWC)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:R
Last Name:DOUTRE
Suffix:
Gender:F
Credentials:NBC-HWC
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:R
Other - Last Name:LYERLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NBC-HWC
Mailing Address - Street 1:1 JEFFERSON BARRACKS RD
Mailing Address - Street 2:WHOLE HEALTH DEPARTMENT
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63125
Mailing Address - Country:US
Mailing Address - Phone:314-652-4100
Mailing Address - Fax:
Practice Address - Street 1:1 JEFFERSON BARRACKS RD
Practice Address - Street 2:WHOLE HEALTH DEPARTMENT
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63125
Practice Address - Country:US
Practice Address - Phone:314-652-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-22
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOA-3635420171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach