Provider Demographics
NPI:1538457189
Name:LONGWILL, TRACY A (MA, LPCC)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:A
Last Name:LONGWILL
Suffix:
Gender:F
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11220 JORDAN AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-3383
Mailing Address - Country:US
Mailing Address - Phone:505-828-2715
Mailing Address - Fax:505-828-2715
Practice Address - Street 1:11220 JORDAN AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122-3383
Practice Address - Country:US
Practice Address - Phone:505-828-2715
Practice Address - Fax:505-828-2715
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-18
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-0141521101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health