Provider Demographics
NPI:1134819147
Name:DAVIS, TRACEY
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6517 BREEZE BAY PT APT 333
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76131-2357
Mailing Address - Country:US
Mailing Address - Phone:817-247-4623
Mailing Address - Fax:
Practice Address - Street 1:1090 SCHOOLHOUSE RD STE 700
Practice Address - Street 2:
Practice Address - City:HASLET
Practice Address - State:TX
Practice Address - Zip Code:76052-3778
Practice Address - Country:US
Practice Address - Phone:817-247-4623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-11
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68988104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker