Provider Demographics
NPI:1194842211
Name:PENROD-MCCORMICK, TRACI L (LCSW, LIMHP)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:L
Last Name:PENROD-MCCORMICK
Suffix:
Gender:F
Credentials:LCSW, LIMHP
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:L
Other - Last Name:PENROD-MCCORMICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW, LIMHP
Mailing Address - Street 1:820 S 75TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-4623
Mailing Address - Country:US
Mailing Address - Phone:402-391-2477
Mailing Address - Fax:402-397-4268
Practice Address - Street 1:820 S 75TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4623
Practice Address - Country:US
Practice Address - Phone:402-391-2477
Practice Address - Fax:402-397-4268
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1110 1327 35571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical