Provider Demographics
NPI:1023129350
Name:MCKIERNAN, TRACEY ROMAN (LISW-S)
Entity type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:ROMAN
Last Name:MCKIERNAN
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3737 LANDER RD.
Mailing Address - Street 2:
Mailing Address - City:PEPPER PIKE
Mailing Address - State:OH
Mailing Address - Zip Code:44124-1105
Mailing Address - Country:US
Mailing Address - Phone:216-831-2255
Mailing Address - Fax:216-831-0638
Practice Address - Street 1:3737 LANDER RD
Practice Address - Street 2:
Practice Address - City:PEPPER PIKE
Practice Address - State:OH
Practice Address - Zip Code:44124-5712
Practice Address - Country:US
Practice Address - Phone:216-831-2255
Practice Address - Fax:216-831-0638
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010782041041C0700X
OH07000651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801078204OtherSTATE LICENSE