Provider Demographics
NPI:1508465105
Name:BOUSQUET, TRACY HAZAN (LMSW)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:HAZAN
Last Name:BOUSQUET
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 N FULLERTON AVE APT 36
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-3837
Mailing Address - Country:US
Mailing Address - Phone:917-741-5535
Mailing Address - Fax:
Practice Address - Street 1:98120 QUEENS BLVD STE 1C
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4414
Practice Address - Country:US
Practice Address - Phone:718-830-0246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-23
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YA0400X, 101YM0800X, 101YP2500X
NJ44SL065603001041C0700X
NY0947561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional