Provider Demographics
NPI:1629199765
Name:KENLINE, TRACY (LCSW)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:KENLINE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:KENLINE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:740 BURBANK ST
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-1658
Mailing Address - Country:US
Mailing Address - Phone:720-495-7741
Mailing Address - Fax:855-458-4470
Practice Address - Street 1:740 BURBANK ST
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-1658
Practice Address - Country:US
Practice Address - Phone:720-495-7741
Practice Address - Fax:855-458-4470
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW76221041C0700X
CO14531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO12076183OtherCAQH
CO45-2792123OtherTAX ID