Provider Demographics
NPI:1396506317
Name:WATERS, TRACY FAYE (LPC)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:FAYE
Last Name:WATERS
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 1:50 OLD HALL STATION RD
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30145-1418
Mailing Address - Country:US
Mailing Address - Phone:678-346-6274
Mailing Address - Fax:
Practice Address - Street 1:3380 TRICKUM RD STE 700
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-3680
Practice Address - Country:US
Practice Address - Phone:770-591-4770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC013589101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional