Provider Demographics
NPI:1487032512
Name:TREFETHEN, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:TREFETHEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 SE MORRISON ST STE 710
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2347
Mailing Address - Country:US
Mailing Address - Phone:503-908-4779
Mailing Address - Fax:
Practice Address - Street 1:516 SE MORRISON ST STE 710
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2347
Practice Address - Country:US
Practice Address - Phone:503-908-4779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-08
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORC5157101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health