Provider Demographics
NPI:1346743358
Name:TRACE, ASHLEY METRONUS (LMSW)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:METRONUS
Last Name:TRACE
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 S MANITOU AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-4148
Mailing Address - Country:US
Mailing Address - Phone:503-280-1385
Mailing Address - Fax:
Practice Address - Street 1:325 W IDAHO ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6040
Practice Address - Country:US
Practice Address - Phone:208-381-2138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-15
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID37349104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker