Provider Demographics
NPI:1811208838
Name:GEORGE, TRACEY-ANN A (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY-ANN
Middle Name:A
Last Name:GEORGE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:TRACEY-ANN
Other - Middle Name:A
Other - Last Name:BAXTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:306 5TH ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06607-1083
Mailing Address - Country:US
Mailing Address - Phone:203-909-9919
Mailing Address - Fax:
Practice Address - Street 1:20 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06854-2656
Practice Address - Country:US
Practice Address - Phone:209-838-6508
Practice Address - Fax:203-852-7021
Is Sole Proprietor?:No
Enumeration Date:2010-06-24
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CT0082551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235918Medicaid