Provider Demographics
NPI:1710527718
Name:ANDERSON, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:ANDERSON
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:PO BOX 35
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:IN
Mailing Address - Zip Code:47558-0035
Mailing Address - Country:US
Mailing Address - Phone:812-486-9019
Mailing Address - Fax:
Practice Address - Street 1:11 NE 3RD ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IN
Practice Address - Zip Code:47501-2903
Practice Address - Country:US
Practice Address - Phone:812-486-9019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39003441A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health