Provider Demographics
NPI:1811419617
Name:ETTER, TRACIE MICHELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:MICHELLE
Last Name:ETTER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9030 STEWARTSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MONETA
Mailing Address - State:VA
Mailing Address - Zip Code:24121-4762
Mailing Address - Country:US
Mailing Address - Phone:540-797-9620
Mailing Address - Fax:
Practice Address - Street 1:1120 BYPASS ROAD
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:VA
Practice Address - Zip Code:24179-2417
Practice Address - Country:US
Practice Address - Phone:540-767-2667
Practice Address - Fax:540-767-2669
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-13
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040099001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical