Provider Demographics
NPI:1326584038
Name:SEBASTIAN EVANS, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:SEBASTIAN EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:474 N YELLOW SPRINGS ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504-2463
Mailing Address - Country:US
Mailing Address - Phone:937-399-9500
Mailing Address - Fax:937-342-4242
Practice Address - Street 1:416 XENIA AVE
Practice Address - Street 2:
Practice Address - City:YELLOW SPRINGS
Practice Address - State:OH
Practice Address - Zip Code:45387-1836
Practice Address - Country:US
Practice Address - Phone:937-767-9171
Practice Address - Fax:937-767-9175
Is Sole Proprietor?:No
Enumeration Date:2017-01-19
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.18007571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical