Provider Demographics
NPI:1700544756
Name:FOSTER, TRACIE MICHELLE
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:MICHELLE
Last Name:FOSTER
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 1:5522 ROBBINS DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-1593
Mailing Address - Country:US
Mailing Address - Phone:347-803-8273
Mailing Address - Fax:
Practice Address - Street 1:2101 GARNER RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-0114
Practice Address - Country:US
Practice Address - Phone:919-787-6131
Practice Address - Fax:919-571-2932
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-07
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-27512101YA0400X
NCA18223101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty