Provider Demographics
NPI:1942060017
Name:WELLMAN, TRACY LEE (LCSW)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LEE
Last Name:WELLMAN
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 1:228 FOUNTAIN LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-3833
Mailing Address - Country:US
Mailing Address - Phone:407-748-9650
Mailing Address - Fax:
Practice Address - Street 1:1620 MASON AVE STE C
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5513
Practice Address - Country:US
Practice Address - Phone:386-366-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW168861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical