Provider Demographics
NPI:1457498511
Name:VANNORSDALL, TRACY D (PHD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:D
Last Name:VANNORSDALL
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 1:600 N WOLFE ST
Mailing Address - Street 2:MEYER 218
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21287-0005
Mailing Address - Country:US
Mailing Address - Phone:410-955-3268
Mailing Address - Fax:410-955-0504
Practice Address - Street 1:600 N WOLFE ST
Practice Address - Street 2:MEYER 218
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0005
Practice Address - Country:US
Practice Address - Phone:410-955-3268
Practice Address - Fax:410-955-0504
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD390200000X
MD04467103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD023328500Medicaid
MD023328500Medicaid