Provider Demographics
NPI:1568004182
Name:DANTZLER, TRACY L (SUDP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:DANTZLER
Suffix:
Gender:F
Credentials:SUDP
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:L
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SUDP
Mailing Address - Street 1:101 E MAGNESIUM RD STE 101
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-5901
Mailing Address - Country:US
Mailing Address - Phone:509-368-9021
Mailing Address - Fax:509-474-1796
Practice Address - Street 1:10305 E MONTGOMERY DR
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-4220
Practice Address - Country:US
Practice Address - Phone:509-418-2108
Practice Address - Fax:509-315-9386
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-15
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00002768101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)