Provider Demographics
NPI:1003663477
Name:LETOURNEAU, TRACEY (LMSW)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:LETOURNEAU
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 BENFIELD BLVD STE G
Mailing Address - Street 2:
Mailing Address - City:MILLERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21108-2589
Mailing Address - Country:US
Mailing Address - Phone:443-591-6418
Mailing Address - Fax:
Practice Address - Street 1:1114 BENFIELD BLVD STE G
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-2589
Practice Address - Country:US
Practice Address - Phone:443-591-6418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-03
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD29643101YM0800X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health