Provider Demographics
NPI:1770856502
Name:CARMODY, TRACY ELIZABETH (MS, LMHC, NCC, CASAC)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:ELIZABETH
Last Name:CARMODY
Suffix:
Gender:F
Credentials:MS, LMHC, NCC, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 DEWITT ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-2890
Mailing Address - Country:US
Mailing Address - Phone:315-719-7117
Mailing Address - Fax:
Practice Address - Street 1:112 DEWITT ST
Practice Address - Street 2:STE 205A
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-2890
Practice Address - Country:US
Practice Address - Phone:315-719-7117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-09
Last Update Date:2012-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004833101Y00000X, 101YM0800X
NY22841101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health