Provider Demographics
NPI:1326249970
Name:HEDRICK, TRACI MOSS (LAC, CCDP, CCGC)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:MOSS
Last Name:HEDRICK
Suffix:
Gender:F
Credentials:LAC, CCDP, CCGC
Other - Prefix:MISS
Other - First Name:TRACI
Other - Middle Name:
Other - Last Name:MOSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4105 KIRKMAN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70607-4603
Mailing Address - Country:US
Mailing Address - Phone:337-475-8022
Mailing Address - Fax:337-475-8054
Practice Address - Street 1:4105 KIRKMAN ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-4603
Practice Address - Country:US
Practice Address - Phone:337-475-8022
Practice Address - Fax:337-475-8054
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALAC 1122101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CV41Medicare ID - Type Unspecified