Provider Demographics
NPI:1992207690
Name:TRACY CLOUGH, LCSW, LLC
Entity Type:Organization
Organization Name:TRACY CLOUGH, LCSW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:973-809-4722
Mailing Address - Street 1:298 PARK LN
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-2254
Mailing Address - Country:US
Mailing Address - Phone:973-809-4722
Mailing Address - Fax:
Practice Address - Street 1:515 BRIDGEPORT AVE
Practice Address - Street 2:JOURNEY TO WELLNESS SUITE
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484
Practice Address - Country:US
Practice Address - Phone:203-814-8113
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT010006251S00000X, 261QM0801X, 261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health