Provider Demographics
NPI:1952677510
Name:PEARSON-HEANEY, TRACEY SUE (MA, LPC, LCPC)
Entity Type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:SUE
Last Name:PEARSON-HEANEY
Suffix:
Gender:F
Credentials:MA, LPC, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 N KIRKWOOD RD STE 102
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-4042
Mailing Address - Country:US
Mailing Address - Phone:618-444-8589
Mailing Address - Fax:
Practice Address - Street 1:2148 VADALABENE DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5632
Practice Address - Country:US
Practice Address - Phone:618-288-3100
Practice Address - Fax:618-288-3371
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-28
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014021704101YP2500X
IL180009843101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490055312Medicaid