Provider Demographics
NPI:1275884017
Name:WINE, TRACY ANN (MSW, LGSW)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:ANN
Last Name:WINE
Suffix:
Gender:F
Credentials:MSW, LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 SCOTT AVE.
Mailing Address - Street 2:VALLEY HEALTHCARE SYSTEM
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508
Mailing Address - Country:US
Mailing Address - Phone:304-296-1731
Mailing Address - Fax:304-225-2288
Practice Address - Street 1:448 LEONARD AVE.
Practice Address - Street 2:VALLEY HEALTHCARE SYSTEM
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554
Practice Address - Country:US
Practice Address - Phone:304-296-1731
Practice Address - Fax:304-225-2288
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVBP00944095104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker