Provider Demographics
NPI:1376735928
Name:HILLARD, TRACIE LYNN (MS, MDIV, LPC)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:LYNN
Last Name:HILLARD
Suffix:
Gender:F
Credentials:MS, MDIV, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 MALLOY ST STE E
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-4478
Mailing Address - Country:US
Mailing Address - Phone:919-778-5594
Mailing Address - Fax:
Practice Address - Street 1:208 MALLOY ST STE E
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-4478
Practice Address - Country:US
Practice Address - Phone:919-778-5594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-16
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4510101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103678Medicaid