Provider Demographics
NPI:1578005591
Name:DECKER, TRACI
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:DECKER
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:PO BOX 366
Mailing Address - Street 2:36 PUBLIC AVE
Mailing Address - City:MONTROSE
Mailing Address - State:PA
Mailing Address - Zip Code:18801-1603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36 PUBLIC AVE
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:PA
Practice Address - Zip Code:18801-1603
Practice Address - Country:US
Practice Address - Phone:570-278-3338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)