Provider Demographics
NPI:1295945707
Name:BRUBAKER, TRACEY ANNE (LCSW, CMSW)
Entity type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:ANNE
Last Name:BRUBAKER
Suffix:
Gender:F
Credentials:LCSW, CMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4027 BARCLAY FOREST DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-4848
Mailing Address - Country:US
Mailing Address - Phone:704-497-4774
Mailing Address - Fax:
Practice Address - Street 1:1300 BLYTHE BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5873
Practice Address - Country:US
Practice Address - Phone:704-372-4663
Practice Address - Fax:704-339-0706
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0055701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106622Medicaid