Provider Demographics
NPI:1245392281
Name:THOMAS, TRACEY LYNN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:LYNN
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:LYNN
Other - Last Name:CARTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1017 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:POCAHONTAS
Mailing Address - State:IL
Mailing Address - Zip Code:62275
Mailing Address - Country:US
Mailing Address - Phone:618-541-8410
Mailing Address - Fax:618-651-0433
Practice Address - Street 1:1017 MAIN STREET
Practice Address - Street 2:
Practice Address - City:POCAHONTAS
Practice Address - State:IL
Practice Address - Zip Code:62275
Practice Address - Country:US
Practice Address - Phone:618-541-8410
Practice Address - Fax:618-651-0433
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490099711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical