Provider Demographics
NPI:1932320942
Name:THOMAS, TRACY WAYNE (MED, LPC)
Entity Type:Individual
Prefix:MR
First Name:TRACY
Middle Name:WAYNE
Last Name:THOMAS
Suffix:
Gender:M
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2660 E END BLVD S
Mailing Address - Street 2:SUITE 128
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75672-7404
Mailing Address - Country:US
Mailing Address - Phone:903-407-9701
Mailing Address - Fax:
Practice Address - Street 1:2660 E END BLVD S
Practice Address - Street 2:SUITE 128
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75672-7404
Practice Address - Country:US
Practice Address - Phone:903-407-9701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19851101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1762403-01Medicaid