Provider Demographics
NPI:1013245737
Name:SASHIDHARAN, TRACY LYNN (LCPC)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:SASHIDHARAN
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-0098
Mailing Address - Country:US
Mailing Address - Phone:618-710-4123
Mailing Address - Fax:
Practice Address - Street 1:9 JUNCTION DR W STE 3
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-2931
Practice Address - Country:US
Practice Address - Phone:618-710-4123
Practice Address - Fax:618-731-4082
Is Sole Proprietor?:No
Enumeration Date:2009-11-19
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
IL018.0007365101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional