Provider Demographics
NPI:1225725112
Name:DWYER, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:DWYER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1911 GRAYSON HWY STE 8-242
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-1245
Mailing Address - Country:US
Mailing Address - Phone:678-632-4995
Mailing Address - Fax:
Practice Address - Street 1:1911 GRAYSON HWY STE 8-242
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017-1245
Practice Address - Country:US
Practice Address - Phone:678-632-4995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-20
Last Update Date:2023-12-05
Deactivation Date:2023-10-24
Deactivation Code:
Reactivation Date:2023-12-05
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical