Provider Demographics
NPI:1326405788
Name:MALONE, TRACEY MARIE (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:MARIE
Last Name:MALONE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2506
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-2506
Mailing Address - Country:US
Mailing Address - Phone:218-454-0878
Mailing Address - Fax:218-454-0879
Practice Address - Street 1:7251 EXCELSIOR RD
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425
Practice Address - Country:US
Practice Address - Phone:218-454-0878
Practice Address - Fax:218-454-0879
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-15
Last Update Date:2018-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2869106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist