Provider Demographics
NPI:1609052596
Name:BIRMINGHAM, TRACY R (LAC)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:R
Last Name:BIRMINGHAM
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 MISSOURI
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:AR
Mailing Address - Zip Code:72342-3707
Mailing Address - Country:US
Mailing Address - Phone:870-338-3363
Mailing Address - Fax:870-933-9395
Practice Address - Street 1:211 MISSOURI
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:AR
Practice Address - Zip Code:72342-3707
Practice Address - Country:US
Practice Address - Phone:870-338-3363
Practice Address - Fax:870-933-9395
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-10
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR173795795Medicaid