Provider Demographics
NPI:1386671352
Name:AGOSTIN, TRACY MCKEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:MCKEE
Last Name:AGOSTIN
Suffix:
Gender:F
Credentials:PHD
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 382391
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38183-2391
Mailing Address - Country:US
Mailing Address - Phone:901-756-8398
Mailing Address - Fax:901-756-8701
Practice Address - Street 1:8820 TRINITY RD STE 202
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-2735
Practice Address - Country:US
Practice Address - Phone:901-756-8398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1727103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN14C182000Medicaid
TN3583645Medicare ID - Type Unspecified