Provider Demographics
NPI:1528579026
Name:SELVAGE, TRACY (CDCA)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:SELVAGE
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1549 JOHNSON HILL RD
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:OH
Mailing Address - Zip Code:45690-8954
Mailing Address - Country:US
Mailing Address - Phone:740-947-1782
Mailing Address - Fax:
Practice Address - Street 1:15221 STATE ROUTE 772
Practice Address - Street 2:
Practice Address - City:PIKETON
Practice Address - State:OH
Practice Address - Zip Code:45661-9062
Practice Address - Country:US
Practice Address - Phone:740-493-4260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-24
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH150092101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)