Provider Demographics
NPI:1417067539
Name:SMITH, TRACY LYNN (MA)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4407 MACCORKLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-2541
Mailing Address - Country:US
Mailing Address - Phone:304-925-0800
Mailing Address - Fax:304-905-0805
Practice Address - Street 1:4407 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-2541
Practice Address - Country:US
Practice Address - Phone:304-925-0800
Practice Address - Fax:304-925-0805
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV785103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9205040000Medicaid