Provider Demographics
NPI:1558321265
Name:LEE, TRACY WILSON (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:WILSON
Last Name:LEE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:TRACY
Other - Middle Name:LEE
Other - Last Name:BEMISTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:328 CHATHAM RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-3316
Mailing Address - Country:US
Mailing Address - Phone:614-456-9842
Mailing Address - Fax:614-456-9842
Practice Address - Street 1:130 NORTHWOODS BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-7473
Practice Address - Country:US
Practice Address - Phone:614-456-9842
Practice Address - Fax:614-456-9842
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6534103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist