Provider Demographics
NPI:1396778445
Name:CARSON, TRACEY LIZABETH (LCSW)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:LIZABETH
Last Name:CARSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 WILLOW BROOK CIR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-3490
Mailing Address - Country:US
Mailing Address - Phone:502-254-7763
Mailing Address - Fax:
Practice Address - Street 1:8135 NEW LAGRANGE ROAD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222
Practice Address - Country:US
Practice Address - Phone:502-254-7763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYL6401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYCSW0145Medicare ID - Type Unspecified