Provider Demographics
NPI:1669957544
Name:ROYSTER-BENNETT, TRACEY ANDREA
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:ANDREA
Last Name:ROYSTER-BENNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 LIGHT ST UNIT 1301
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-1269
Mailing Address - Country:US
Mailing Address - Phone:443-927-5050
Mailing Address - Fax:
Practice Address - Street 1:3455 WILKENS AVE STE 203
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-5265
Practice Address - Country:US
Practice Address - Phone:443-927-5050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitationGroup - Single Specialty