Provider Demographics
NPI:1740604933
Name:CARLOS, TRACI (MA)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:CARLOS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2711 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6818
Mailing Address - Country:US
Mailing Address - Phone:803-726-9317
Mailing Address - Fax:
Practice Address - Street 1:2711 COLONIAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6818
Practice Address - Country:US
Practice Address - Phone:803-726-9317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-10
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)