Provider Demographics
NPI:1497287809
Name:BRACEY, TINA LOUISE (MA, LPC)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:LOUISE
Last Name:BRACEY
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:MRS
Other - First Name:TINA
Other - Middle Name:LOUISE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LPC
Mailing Address - Street 1:PO BOX 367
Mailing Address - Street 2:
Mailing Address - City:SOUTH HILL
Mailing Address - State:VA
Mailing Address - Zip Code:23970-0367
Mailing Address - Country:US
Mailing Address - Phone:434-584-9434
Mailing Address - Fax:888-722-4701
Practice Address - Street 1:114 SOUTH HILL AVENUE
Practice Address - Street 2:
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970-3240
Practice Address - Country:US
Practice Address - Phone:434-584-9434
Practice Address - Fax:888-722-4701
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-03
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701008125101Y00000X, 101YM0800X, 101YP2500X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2019022734Medicaid