Provider Demographics
NPI:1568982635
Name:TOLBERT, TRACEY
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:TOLBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 S. ACADIAN THRUWAY
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-6900
Mailing Address - Country:US
Mailing Address - Phone:225-223-6968
Mailing Address - Fax:225-442-1396
Practice Address - Street 1:1200 S ACADIAN THRUWAY
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806
Practice Address - Country:US
Practice Address - Phone:225-223-6968
Practice Address - Fax:225-442-1396
Is Sole Proprietor?:No
Enumeration Date:2017-06-21
Last Update Date:2017-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA473292439Medicaid