Provider Demographics
NPI:1245484260
Name:EDMONDS, TRACIE MCCOY (LPC)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:MCCOY
Last Name:EDMONDS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3909 BIRDBROOK DR
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-1691
Mailing Address - Country:US
Mailing Address - Phone:804-520-0153
Mailing Address - Fax:
Practice Address - Street 1:5024 BRYANBELL LN
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23234-8004
Practice Address - Country:US
Practice Address - Phone:804-279-8995
Practice Address - Fax:804-279-8996
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003763101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional