Provider Demographics
NPI:1184761520
Name:KLUCINA, TRACY LOU (LCAS)
Entity type:Individual
Prefix:MS
First Name:TRACY
Middle Name:LOU
Last Name:KLUCINA
Suffix:
Gender:F
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3430 WHEATLEY AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-7654
Mailing Address - Country:US
Mailing Address - Phone:704-591-2026
Mailing Address - Fax:704-336-6559
Practice Address - Street 1:3430 WHEATLEY AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-7654
Practice Address - Country:US
Practice Address - Phone:704-591-2026
Practice Address - Fax:704-336-6559
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC944101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6111873Medicaid