Provider Demographics
NPI:1225347198
Name:LARGETT, TRACY ANN (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:ANN
Last Name:LARGETT
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MISS
Other - First Name:TRACY
Other - Middle Name:ANN
Other - Last Name:DERRIGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17513 COUNTY ROUTE 91
Mailing Address - Street 2:
Mailing Address - City:ADAMS
Mailing Address - State:NY
Mailing Address - Zip Code:13605-2237
Mailing Address - Country:US
Mailing Address - Phone:315-465-7979
Mailing Address - Fax:
Practice Address - Street 1:1351 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4531
Practice Address - Country:US
Practice Address - Phone:315-779-5617
Practice Address - Fax:315-785-3769
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-27
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0628211041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool