Provider Demographics
NPI:1790867513
Name:DAWYDUK, TRACY M (PSYD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:M
Last Name:DAWYDUK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4833 DARROW RD STE 101
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-1411
Mailing Address - Country:US
Mailing Address - Phone:330-650-5338
Mailing Address - Fax:330-342-3837
Practice Address - Street 1:4833 DARROW RD STE 101
Practice Address - Street 2:
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224-1411
Practice Address - Country:US
Practice Address - Phone:330-650-5338
Practice Address - Fax:330-342-3837
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5685103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000316465OtherANTHEM
OH000000316465OtherANTHEM
OHCP24413Medicare ID - Type Unspecified
OHCP24412Medicare ID - Type Unspecified