Provider Demographics
NPI:1710076393
Name:TRACY, CHARLES C (LICSW)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:C
Last Name:TRACY
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1281 RAYMOND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-1817
Mailing Address - Country:US
Mailing Address - Phone:651-644-4408
Mailing Address - Fax:612-436-2606
Practice Address - Street 1:717 E RIVER PKWY
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0369
Practice Address - Country:US
Practice Address - Phone:612-436-4800
Practice Address - Fax:612-436-2606
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN017541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical