Provider Demographics
NPI:1508486440
Name:ROSS, TRACEY SHANIECE (LSW)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:SHANIECE
Last Name:ROSS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 SHERMAN AVE APT 10
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07502-1753
Mailing Address - Country:US
Mailing Address - Phone:201-873-5827
Mailing Address - Fax:
Practice Address - Street 1:173 SHERMAN AVE APT 10
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07502-1753
Practice Address - Country:US
Practice Address - Phone:201-873-5827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-21
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06361800104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker