Provider Demographics
NPI:1265515027
Name:BEAGLE, TRACEY ANNE
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:ANNE
Last Name:BEAGLE
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 1:12220 SW 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-2828
Mailing Address - Country:US
Mailing Address - Phone:503-644-7242
Mailing Address - Fax:
Practice Address - Street 1:12220 SW 2ND ST
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2828
Practice Address - Country:US
Practice Address - Phone:503-644-7242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164936Medicaid