Provider Demographics
NPI:1467435875
Name:SCHULDEN, TRACY LEE DIVELY (LCSW-C)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LEE DIVELY
Last Name:SCHULDEN
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 SEVERN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-1740
Mailing Address - Country:US
Mailing Address - Phone:410-752-5525
Mailing Address - Fax:
Practice Address - Street 1:1401 SEVERN ST STE 201
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230-1740
Practice Address - Country:US
Practice Address - Phone:410-752-5525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD078291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD65080OtherVALUE OPTIONS
T5140008OtherREGIONAL BLUE CHOICE
MD54688502OtherMD RENDERING NUMBER
MD198041000OtherMAGELLAN BEHAVIORAL HEALT
MD212150600QMedicaid
MDKC29UNOtherCAREFIRST BC/BS
826L047EMedicare ID - Type Unspecified