Provider Demographics
NPI:1407859465
Name:ANDERSON, TRACIE L (LCSW)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-3554
Mailing Address - Country:US
Mailing Address - Phone:812-282-1888
Mailing Address - Fax:812-218-9318
Practice Address - Street 1:510 SPRING ST
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3554
Practice Address - Country:US
Practice Address - Phone:812-282-1888
Practice Address - Fax:812-218-9318
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2015-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34000315A1041C0700X
KY8071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2767013000OtherPASSPORT ADVANTAGE
KY82900176OtherMEDICAID KENTUCKY GROUP
IN160780OtherMEDICARE GROUP
000000056294OtherANTHEM GROUP
KY2444451000OtherPASSPORT GROUP
IN160860OtherMEDICARE GROUP
KY8200076100Medicaid
000000226075OtherANTHEM
264003000OtherBR BUTLER'S MIS
50704000OtherMAGELLAN GROUP MIS
INCG3623OtherINDIANA RAILROAD MEDICARE
IN100386460OtherINDIANA MEDICAID GROUP
1518960681OtherDR BUTLER'S NPI
IN800012510OtherMEDICARE RAILROAD
KY78903689OtherMEDICAID KENTUCKY GROUP
94882000OtherMAGELLAN MIS
IN200319860AMedicaid
KY65927857OtherMEDICAID KENTUCKY GROUP
000000226075OtherANTHEM
264003000OtherBR BUTLER'S MIS