Provider Demographics
NPI:1275256455
Name:PATACCA, TRACEY LM
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:LM
Last Name:PATACCA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:L
Other - Last Name:MANDARANO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CDCA
Mailing Address - Street 1:6900 RIDGE RD STE 202
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44129-5650
Mailing Address - Country:US
Mailing Address - Phone:440-887-1100
Mailing Address - Fax:440-887-1103
Practice Address - Street 1:6900 RIDGE RD STE 202
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44129-5650
Practice Address - Country:US
Practice Address - Phone:440-887-1100
Practice Address - Fax:440-887-1103
Is Sole Proprietor?:No
Enumeration Date:2022-09-22
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHCDCA.181643101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator