Provider Demographics
NPI:1316039423
Name:MIKSELL, TRACY (LISW)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:MIKSELL
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:DR
Other - First Name:TRACY
Other - Middle Name:A
Other - Last Name:MIKSELL-BRANCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:215 SE MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GRIMES
Mailing Address - State:IA
Mailing Address - Zip Code:50111-2192
Mailing Address - Country:US
Mailing Address - Phone:515-490-1921
Mailing Address - Fax:515-986-5902
Practice Address - Street 1:215 SE MAIN ST
Practice Address - Street 2:
Practice Address - City:GRIMES
Practice Address - State:IA
Practice Address - Zip Code:50111-2192
Practice Address - Country:US
Practice Address - Phone:515-490-1921
Practice Address - Fax:515-986-5902
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02517104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI15141Medicare ID - Type Unspecified
IAI11382Medicare PIN