Provider Demographics
NPI:1396967956
Name:CLARK, TRACEY ELIZABETH (MSW)
Entity type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:ELIZABETH
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3229 ELLSWORTH ST. N.E.
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24012-3618
Mailing Address - Country:US
Mailing Address - Phone:540-366-4950
Mailing Address - Fax:
Practice Address - Street 1:775 DENT ROAD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-4116
Practice Address - Country:US
Practice Address - Phone:540-265-4281
Practice Address - Fax:540-265-4287
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker