Provider Demographics
NPI:1699223230
Name:ELBERT, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:ELBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5352 FAIRFAX AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71108-3334
Mailing Address - Country:US
Mailing Address - Phone:318-751-3053
Mailing Address - Fax:
Practice Address - Street 1:543 STONER AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4122
Practice Address - Country:US
Practice Address - Phone:318-673-9901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health