Provider Demographics
NPI:1497014344
Name:PRELI-DERWIN, TRACIE LYNN
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:LYNN
Last Name:PRELI-DERWIN
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 1:96 CONNECTICUT BLVD
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-3013
Mailing Address - Country:US
Mailing Address - Phone:860-502-4908
Mailing Address - Fax:860-513-4828
Practice Address - Street 1:96 CONNECTICUT BLVD
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-3013
Practice Address - Country:US
Practice Address - Phone:860-502-4908
Practice Address - Fax:860-513-4828
Is Sole Proprietor?:No
Enumeration Date:2012-05-14
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical