Provider Demographics
NPI:1639340300
Name:PEQUIGNOT, TRACY L (LCSW)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:L
Last Name:PEQUIGNOT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7095 ROUTE 287
Mailing Address - Street 2:PO BOX 685
Mailing Address - City:WELLSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16901-6711
Mailing Address - Country:US
Mailing Address - Phone:570-724-5272
Mailing Address - Fax:570-724-4512
Practice Address - Street 1:7095 ROUTE 287
Practice Address - Street 2:
Practice Address - City:WELLSBORO
Practice Address - State:PA
Practice Address - Zip Code:16901
Practice Address - Country:US
Practice Address - Phone:570-724-5272
Practice Address - Fax:570-724-4512
Is Sole Proprietor?:No
Enumeration Date:2008-03-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0157451041C0700X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical