Provider Demographics
NPI:1295027217
Name:PHILLIPS-PERKINS, TRACI LEE (LCSW-R)
Entity type:Individual
Prefix:MS
First Name:TRACI
Middle Name:LEE
Last Name:PHILLIPS-PERKINS
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4176
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-0176
Mailing Address - Country:US
Mailing Address - Phone:518-420-7466
Mailing Address - Fax:
Practice Address - Street 1:453 DIXON RD
Practice Address - Street 2:BLDG. 3 STE. 8
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-1949
Practice Address - Country:US
Practice Address - Phone:518-420-7466
Practice Address - Fax:518-745-5731
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-10
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR073014-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical