Provider Demographics
NPI:1881208650
Name:RANDALL, TRACIE MARIE
Entity Type:Individual
Prefix:PROF
First Name:TRACIE
Middle Name:MARIE
Last Name:RANDALL
Suffix:
Gender:F
Credentials:
Other - Prefix:PROF
Other - First Name:TRACIE
Other - Middle Name:MARIE
Other - Last Name:RANDALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:TRACIE ROMERO LPC
Mailing Address - Street 1:2085 LYNNHAVEN PKWY STE 106
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-1497
Mailing Address - Country:US
Mailing Address - Phone:757-348-2189
Mailing Address - Fax:
Practice Address - Street 1:865 WOODSTOCK ROAD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464
Practice Address - Country:US
Practice Address - Phone:757-348-2189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-31
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701012934101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health