Provider Demographics
NPI:1639785033
Name:MICKELSON, TRACY (CASAC)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:MICKELSON
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1149 SULLIVAN ST STE B
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-1670
Mailing Address - Country:US
Mailing Address - Phone:607-733-7661
Mailing Address - Fax:607-733-7675
Practice Address - Street 1:1149 SULLIVAN ST STE B
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-1670
Practice Address - Country:US
Practice Address - Phone:607-733-7661
Practice Address - Fax:607-733-7675
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)