Provider Demographics
NPI:1235799412
Name:BOLYARD, TRACY A (MSW, LSW)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:A
Last Name:BOLYARD
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:BOLYARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2587 BACK ORRVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-9523
Mailing Address - Country:US
Mailing Address - Phone:330-264-9597
Mailing Address - Fax:330-264-0946
Practice Address - Street 1:2587 BACK ORRVILLE RD
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-9523
Practice Address - Country:US
Practice Address - Phone:330-264-9597
Practice Address - Fax:330-264-0946
Is Sole Proprietor?:No
Enumeration Date:2019-06-19
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHS.1903921104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator