Provider Demographics
NPI:1245741701
Name:FOLLERT, TRACY (LCSW)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:FOLLERT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 CLARK ST
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-4929
Mailing Address - Country:US
Mailing Address - Phone:860-459-4429
Mailing Address - Fax:
Practice Address - Street 1:88 GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2509
Practice Address - Country:US
Practice Address - Phone:203-573-7265
Practice Address - Fax:203-573-7578
Is Sole Proprietor?:No
Enumeration Date:2017-10-23
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT009756101YM0800X
CT97561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health