Provider Demographics
NPI:1396367181
Name:TOMAS, TRACIE RENE
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:RENE
Last Name:TOMAS
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 1:1610 OCONEE SPRINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:STATHAM
Mailing Address - State:GA
Mailing Address - Zip Code:30666-3619
Mailing Address - Country:US
Mailing Address - Phone:770-605-8661
Mailing Address - Fax:
Practice Address - Street 1:250 NORTH AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30601-2244
Practice Address - Country:US
Practice Address - Phone:706-354-3970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-14
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC007270101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health