Provider Demographics
NPI:1316391188
Name:ELLIS, TRACEY (BS,QMHP-C)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:BS,QMHP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:543 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24078-1105
Mailing Address - Country:US
Mailing Address - Phone:276-732-9195
Mailing Address - Fax:
Practice Address - Street 1:212 N UNION ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-1030
Practice Address - Country:US
Practice Address - Phone:276-732-9195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor