Provider Demographics
NPI:1740793538
Name:ALLEN, TRACY MICHELLE
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:MICHELLE
Last Name:ALLEN
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 1:1016 WILDWOOD PKWY
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-1851
Mailing Address - Country:US
Mailing Address - Phone:443-271-0086
Mailing Address - Fax:
Practice Address - Street 1:1016 WILDWOOD PKWY
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-1851
Practice Address - Country:US
Practice Address - Phone:443-271-0086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-15
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15946104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119324400Medicaid