Provider Demographics
NPI:1598515611
Name:WEITZEL, TRACY MARIE (LADC)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:MARIE
Last Name:WEITZEL
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14750 LAC LAVON DR
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-6398
Mailing Address - Country:US
Mailing Address - Phone:952-248-2090
Mailing Address - Fax:952-600-8009
Practice Address - Street 1:14750 LAC LAVON DR
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-6398
Practice Address - Country:US
Practice Address - Phone:952-248-2090
Practice Address - Fax:952-600-8009
Is Sole Proprietor?:No
Enumeration Date:2024-03-22
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305481101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)