Provider Demographics
NPI:1154624955
Name:SELF, TRACIE
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:SELF
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 1:809 GRAY ST
Mailing Address - Street 2:
Mailing Address - City:APLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:50604-1030
Mailing Address - Country:US
Mailing Address - Phone:319-346-1771
Mailing Address - Fax:
Practice Address - Street 1:809 GRAY ST
Practice Address - Street 2:
Practice Address - City:APLINGTON
Practice Address - State:IA
Practice Address - Zip Code:50604-1030
Practice Address - Country:US
Practice Address - Phone:319-346-1771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-16
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001281101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health