Provider Demographics
NPI:1649457912
Name:TRACEY, PAULA (MSW)
Entity type:Individual
Prefix:
First Name:PAULA
Middle Name:
Last Name:TRACEY
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:PAULA
Other - Middle Name:
Other - Last Name:GRAEBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1401 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-2407
Mailing Address - Country:US
Mailing Address - Phone:218-730-2344
Mailing Address - Fax:
Practice Address - Street 1:1401 E 1ST ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2407
Practice Address - Country:US
Practice Address - Phone:218-730-2344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-29
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN171471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40977500Medicaid