Provider Demographics
NPI:1851488597
Name:BRUBAKER, TRACY ELAINE (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:ELAINE
Last Name:BRUBAKER
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 MILK ST.
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WESTBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01581
Mailing Address - Country:US
Mailing Address - Phone:508-340-1170
Mailing Address - Fax:
Practice Address - Street 1:69 MILK ST
Practice Address - Street 2:SUITE 201
Practice Address - City:WESTBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01581
Practice Address - Country:US
Practice Address - Phone:508-340-1170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1121401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA494416Medicare UPIN
MABR P23684Medicare ID - Type UnspecifiedPART B
MA104 04 80Medicare UPIN
MA11458617Medicare UPIN
MA60054Medicare UPIN
MAP08474Medicare UPIN
MA2249403Medicare UPIN
MA550010006782Medicare UPIN