Provider Demographics
NPI:1417393869
Name:GROVE, TRACY MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:MARIE
Last Name:GROVE
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 1:1909 S 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4842
Mailing Address - Country:US
Mailing Address - Phone:208-863-3450
Mailing Address - Fax:
Practice Address - Street 1:1909 S 10TH AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4842
Practice Address - Country:US
Practice Address - Phone:208-863-3450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-13
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-329041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical