Provider Demographics
NPI:1649216813
Name:WILLIAMS, TRACY RENEE (LICSW)
Entity type:Individual
Prefix:MS
First Name:TRACY
Middle Name:RENEE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MS
Other - First Name:TRACY
Other - Middle Name:RENEE
Other - Last Name:ROTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 121F
Mailing Address - Street 2:
Mailing Address - City:RUSHFORD
Mailing Address - State:MN
Mailing Address - Zip Code:55971-9636
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:970 RAYMOND AVE STE 105
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1701
Practice Address - Country:US
Practice Address - Phone:612-757-0720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN474376800Medicaid