Provider Demographics
NPI:1922330968
Name:BOUBACAR, TRACEY ARLENE (MS,MSW,LCSW)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:ARLENE
Last Name:BOUBACAR
Suffix:
Gender:F
Credentials:MS,MSW,LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:284 EXECUTIVE PARK DR
Mailing Address - Street 2:SUITE100
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1831
Mailing Address - Country:US
Mailing Address - Phone:704-939-1100
Mailing Address - Fax:
Practice Address - Street 1:405 NC HWY 65
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-8882
Practice Address - Country:US
Practice Address - Phone:336-342-8316
Practice Address - Fax:336-342-8352
Is Sole Proprietor?:No
Enumeration Date:2010-02-01
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC005729104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ36413AMedicare PIN