Provider Demographics
NPI: | 1730291055 |
---|---|
Name: | LUDTKE, TRACI (LBSW & EIS) |
Entity Type: | Individual |
Prefix: | |
First Name: | TRACI |
Middle Name: | |
Last Name: | LUDTKE |
Suffix: | |
Gender: | F |
Credentials: | LBSW & EIS |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1005 MIDWESTERN PKWY |
Mailing Address - Street 2: | |
Mailing Address - City: | WICHITA FALLS |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 76302-2211 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 940-322-0771 |
Mailing Address - Fax: | 940-766-4942 |
Practice Address - Street 1: | 1005 MIDWESTERN PKWY |
Practice Address - Street 2: | |
Practice Address - City: | WICHITA FALLS |
Practice Address - State: | TX |
Practice Address - Zip Code: | 76302-2211 |
Practice Address - Country: | US |
Practice Address - Phone: | 940-322-0771 |
Practice Address - Fax: | 940-766-4942 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-08-31 |
Last Update Date: | 2007-07-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | 37529 | 1041C0700X |
TX | 174400000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Not Answered | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical |
Not Answered | 174400000X | Other Service Providers | Specialist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 00T22Y | Other | BCBS # |
TX | 456554 | Medicare ID - Type Unspecified | MEDICARE # |