Provider Demographics
NPI:1659369239
Name:ISERHOTT, TRACEY LEE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:LEE
Last Name:ISERHOTT
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 1:645 WAVERLY DRIVE SE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97322
Mailing Address - Country:US
Mailing Address - Phone:541-570-9234
Mailing Address - Fax:
Practice Address - Street 1:645 WAVERLY DRIVE SE
Practice Address - Street 2:SUITE 208
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322
Practice Address - Country:US
Practice Address - Phone:541-570-9234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-08
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL32471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR277795Medicaid
OR114399Medicare ID - Type Unspecified
OR277795Medicaid