Provider Demographics
NPI:1003429937
Name:MANRY, TRACI RENEE (LPC)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:RENEE
Last Name:MANRY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15396 N 83RD AVE STE G103
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-5629
Mailing Address - Country:US
Mailing Address - Phone:925-709-4044
Mailing Address - Fax:480-247-4179
Practice Address - Street 1:15396 N 83RD AVE STE G103
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5629
Practice Address - Country:US
Practice Address - Phone:925-709-4044
Practice Address - Fax:925-709-4044
Is Sole Proprietor?:No
Enumeration Date:2020-08-29
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LPC19276101YP2500X
AZLAC-17108101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional