Provider Demographics
NPI:1013677038
Name:BROWN, TRACY LYNETTE (BEHAVIOR SUPPORT TEC)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNETTE
Last Name:BROWN
Suffix:
Gender:F
Credentials:BEHAVIOR SUPPORT TEC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3863 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-4009
Mailing Address - Country:US
Mailing Address - Phone:314-664-3927
Mailing Address - Fax:314-664-0556
Practice Address - Street 1:3863 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-4009
Practice Address - Country:US
Practice Address - Phone:314-664-3927
Practice Address - Fax:314-664-0556
Is Sole Proprietor?:No
Enumeration Date:2021-12-20
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician