Provider Demographics
NPI:1619267051
Name:WHITE, TRACEY ANTIONETTE (MSW, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:ANTIONETTE
Last Name:WHITE
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6720 LAKESIDE HILLS DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-5214
Mailing Address - Country:US
Mailing Address - Phone:314-877-9045
Mailing Address - Fax:
Practice Address - Street 1:6720 LAKESIDE HILLS DR
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-5214
Practice Address - Country:US
Practice Address - Phone:314-877-9045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-18
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20110073881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical