Provider Demographics
NPI:1770002271
Name:LEE, TRACI L
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:L
Last Name:LEE
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 605
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98666-0605
Mailing Address - Country:US
Mailing Address - Phone:360-302-1199
Mailing Address - Fax:
Practice Address - Street 1:309 W 12TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660-2903
Practice Address - Country:US
Practice Address - Phone:360-302-1199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-15
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
WAMC61191722101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator