Provider Demographics
NPI:1700296035
Name:LEWIS, TRACY (LCSW)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-1869
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418-1869
Practice Address - Country:US
Practice Address - Phone:203-954-0543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-08
Last Update Date:2021-06-17
Deactivation Date:2018-07-03
Deactivation Code:
Reactivation Date:2018-07-10
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 104100000X
CT104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker