Provider Demographics
NPI:1508676925
Name:SURBER, TRACI BROOKE (PSYD)
Entity type:Individual
Prefix:DR
First Name:TRACI
Middle Name:BROOKE
Last Name:SURBER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7515 STATE ROUTE 28
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45135-9105
Mailing Address - Country:US
Mailing Address - Phone:937-603-6947
Mailing Address - Fax:
Practice Address - Street 1:7515 STATE ROUTE 28
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:OH
Practice Address - Zip Code:45135-9105
Practice Address - Country:US
Practice Address - Phone:937-603-6947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7570103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical