Provider Demographics
NPI:1942665567
Name:MARSHALL, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 GRIMES RD
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-6725
Mailing Address - Country:US
Mailing Address - Phone:678-366-6050
Mailing Address - Fax:678-366-6051
Practice Address - Street 1:255 GRIMES RD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-6725
Practice Address - Country:US
Practice Address - Phone:678-366-6050
Practice Address - Fax:678-366-6051
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-25
Last Update Date:2015-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA320900000X320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities