Provider Demographics
NPI:1174008254
Name:KING, TRACEY COLLEEN (LICSW)
Entity Type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:COLLEEN
Last Name:KING
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:NORTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01532-1842
Mailing Address - Country:US
Mailing Address - Phone:508-868-0967
Mailing Address - Fax:508-797-1400
Practice Address - Street 1:92 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:NORTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01532-1842
Practice Address - Country:US
Practice Address - Phone:508-868-0967
Practice Address - Fax:508-797-1400
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA111187104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA111187OtherLICSW