Provider Demographics
NPI:1659910503
Name:FORD, TRACIE M (LCSW)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:M
Last Name:FORD
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 1:3770 HAMPTON HILLS DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33810-3867
Mailing Address - Country:US
Mailing Address - Phone:856-434-3357
Mailing Address - Fax:
Practice Address - Street 1:3770 HAMPTON HILLS DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33810-3867
Practice Address - Country:US
Practice Address - Phone:856-434-3357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-24
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00313600101YA0400X
FLSW212241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)