Provider Demographics
NPI:1689302317
Name:SUDTELGTE, TRACY (LMSW)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:SUDTELGTE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 NE RICE RD
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-5849
Mailing Address - Country:US
Mailing Address - Phone:816-347-3069
Mailing Address - Fax:816-347-3200
Practice Address - Street 1:7001 BLUE RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:RAYTOWN
Practice Address - State:MO
Practice Address - Zip Code:64133-5629
Practice Address - Country:US
Practice Address - Phone:816-966-0900
Practice Address - Fax:816-347-3200
Is Sole Proprietor?:No
Enumeration Date:2022-08-10
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021016829104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2021016829OtherMO LICENSE