Provider Demographics
NPI:1295387793
Name:SHEARD, TRACI (MHS, CAC-AD)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:SHEARD
Suffix:
Gender:F
Credentials:MHS, CAC-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6182 RED FOX PL
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-4450
Mailing Address - Country:US
Mailing Address - Phone:410-903-1070
Mailing Address - Fax:
Practice Address - Street 1:1209 WINCHESTER ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217-2735
Practice Address - Country:US
Practice Address - Phone:410-903-1070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC2392101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)