Provider Demographics
NPI:1366869596
Name:SMITH, TRACEY (CADC,LPCC)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:CADC,LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 ROCKWOOD LN
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-9415
Mailing Address - Country:US
Mailing Address - Phone:606-436-5761
Mailing Address - Fax:606-436-5797
Practice Address - Street 1:3830 HIGHWAY 15 S
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339-8675
Practice Address - Country:US
Practice Address - Phone:606-666-7591
Practice Address - Fax:606-666-8364
Is Sole Proprietor?:No
Enumeration Date:2014-03-26
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY103847101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100297940Medicaid