Provider Demographics
NPI:1639392046
Name:PALM, TRACY LEANE (MS, BCBA, LBA)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:LEANE
Last Name:PALM
Suffix:
Gender:F
Credentials:MS, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4703 OAK RD
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38002-9742
Mailing Address - Country:US
Mailing Address - Phone:901-586-5333
Mailing Address - Fax:901-504-3040
Practice Address - Street 1:6761 STAGE RD
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38134-3867
Practice Address - Country:US
Practice Address - Phone:901-379-8827
Practice Address - Fax:901-244-6153
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLBA0000000266103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
205510099OtherIRS