Provider Demographics
NPI:1619450442
Name:TRACY, MIA CATHERINE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MIA
Middle Name:CATHERINE
Last Name:TRACY
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 1:301 MOUNTAIN CREST DR
Mailing Address - Street 2:
Mailing Address - City:WIMBERLEY
Mailing Address - State:TX
Mailing Address - Zip Code:78676-3307
Mailing Address - Country:US
Mailing Address - Phone:512-422-5060
Mailing Address - Fax:
Practice Address - Street 1:14101 W HWY 290
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78737-9330
Practice Address - Country:US
Practice Address - Phone:512-422-5060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX600421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical