Provider Demographics
NPI:1942515846
Name:BLACKMON, TRACY (MSW, LCSW, LCAS)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:MSW, LCSW, LCAS
Other - Prefix:MRS
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:BLACKMON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW, LCSW, LCAS
Mailing Address - Street 1:305 JACOBS RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-8691
Mailing Address - Country:US
Mailing Address - Phone:919-778-1552
Mailing Address - Fax:
Practice Address - Street 1:1706 WAYNE MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-2240
Practice Address - Country:US
Practice Address - Phone:919-734-6676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-16
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0079241041C0700X
NC18231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical