Provider Demographics
NPI:1003968116
Name:MCCONNELL, TRACIE MERTZ (PHD)
Entity type:Individual
Prefix:DR
First Name:TRACIE
Middle Name:MERTZ
Last Name:MCCONNELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:TRACIE
Other - Middle Name:L
Other - Last Name:MERTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:300 E MCBEE AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:651 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-2504
Practice Address - Country:US
Practice Address - Phone:864-241-2600
Practice Address - Fax:864-454-1130
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC686103G00000X, 103TA0700X, 103TB0200X, 103TC0700X, 103TH0100X, 103TP2701X, 103TR0400X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC680016185OtherMEDICARE RAILROAD
SCPS0262Medicaid
SC680016185OtherMEDICARE RAILROAD