Provider Demographics
NPI:1174641278
Name:MATLOCK, TRACY RENEE (LPC)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:RENEE
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O BOX 1655
Mailing Address - Street 2:
Mailing Address - City:MTN. HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72654
Mailing Address - Country:US
Mailing Address - Phone:870-425-8149
Mailing Address - Fax:
Practice Address - Street 1:18 CR 458
Practice Address - Street 2:
Practice Address - City:MTN. HOME
Practice Address - State:AR
Practice Address - Zip Code:72653
Practice Address - Country:US
Practice Address - Phone:870-425-3547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP0603017101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor