Provider Demographics
NPI:1699189100
Name:THOMAS, TRACY ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:ANN
Last Name:THOMAS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 EMERALD DR
Mailing Address - Street 2:
Mailing Address - City:STORM LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50588-2719
Mailing Address - Country:US
Mailing Address - Phone:712-730-8274
Mailing Address - Fax:
Practice Address - Street 1:712 EMERALD DR
Practice Address - Street 2:
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50588-2719
Practice Address - Country:US
Practice Address - Phone:712-730-8274
Practice Address - Fax:712-248-8655
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-12
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1242103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical