Provider Demographics
NPI:1821423278
Name:BLEVINS, TRACI LYNN (LCSW)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:LYNN
Last Name:BLEVINS
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 1:535 W YELLOWSTONE HWY
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-7507
Mailing Address - Country:US
Mailing Address - Phone:307-233-4277
Mailing Address - Fax:
Practice Address - Street 1:1656 E 12TH ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-4004
Practice Address - Country:US
Practice Address - Phone:307-577-5718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-04
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY9981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical