Provider Demographics
NPI:1194012674
Name:TRACY, BRENDA ANN (LPC)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:ANN
Last Name:TRACY
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 1:1910 COUNTY ROAD 82E
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CO
Mailing Address - Zip Code:80536-9213
Mailing Address - Country:US
Mailing Address - Phone:307-460-0385
Mailing Address - Fax:
Practice Address - Street 1:219 W MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80521-2811
Practice Address - Country:US
Practice Address - Phone:307-460-0385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-05
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4814101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO4814OtherLICENSED PROFESSIONAL COUNSELOR