Provider Demographics
NPI:1467949404
Name:ROBERTS, TRACEY DEANNE (LPC)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:DEANNE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 COMMUNITY
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-8804
Mailing Address - Country:US
Mailing Address - Phone:660-885-8131
Mailing Address - Fax:
Practice Address - Street 1:1780 OLD HIGHWAY 50 E STE 113
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:MO
Practice Address - Zip Code:63084
Practice Address - Country:US
Practice Address - Phone:636-582-8100
Practice Address - Fax:636-583-2885
Is Sole Proprietor?:No
Enumeration Date:2018-04-16
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018011501101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health