Provider Demographics
NPI:1275201725
Name:FAWVER, TRACY R (LMSW)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:R
Last Name:FAWVER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1637
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42302-1637
Mailing Address - Country:US
Mailing Address - Phone:270-689-6500
Mailing Address - Fax:270-689-6677
Practice Address - Street 1:707 BROADWAY BLVD NE STE 500
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2367
Practice Address - Country:US
Practice Address - Phone:505-268-0701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-11646104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker