Provider Demographics
NPI:1700647831
Name:MARTIN, TRACY ILENE (RBT)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:ILENE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 N 77TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66111-2903
Mailing Address - Country:US
Mailing Address - Phone:913-212-8418
Mailing Address - Fax:
Practice Address - Street 1:214 FERREL ST
Practice Address - Street 2:
Practice Address - City:PLATTE CITY
Practice Address - State:MO
Practice Address - Zip Code:64079-9511
Practice Address - Country:US
Practice Address - Phone:816-469-5162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician