Provider Demographics
NPI:1598174096
Name:ANDERSON, TRACI KANE (LCSW)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:KANE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25198 HICKORY LN
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-3402
Mailing Address - Country:US
Mailing Address - Phone:918-279-6324
Mailing Address - Fax:
Practice Address - Street 1:25198 HICKORY LN
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74014-3402
Practice Address - Country:US
Practice Address - Phone:918-279-6324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-08
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK35051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical