Provider Demographics
NPI:1598947046
Name:TRACIE, RENAE (MASTERS)
Entity Type:Individual
Prefix:MRS
First Name:RENAE
Middle Name:
Last Name:TRACIE
Suffix:
Gender:F
Credentials:MASTERS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 S 37TH ST
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-7908
Mailing Address - Country:US
Mailing Address - Phone:918-913-2434
Mailing Address - Fax:
Practice Address - Street 1:1309 S. 37TH ST.
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-7908
Practice Address - Country:US
Practice Address - Phone:918-913-2434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK730947232101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)