Provider Demographics
NPI:1265854475
Name:STONE, TRACIE
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:STONE
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 1:108 N ROWE ST
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-3833
Mailing Address - Country:US
Mailing Address - Phone:918-961-2247
Mailing Address - Fax:
Practice Address - Street 1:205 S ADAIR ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-5201
Practice Address - Country:US
Practice Address - Phone:918-825-4872
Practice Address - Fax:918-825-4873
Is Sole Proprietor?:No
Enumeration Date:2014-01-08
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200240050AMedicaid