Provider Demographics
NPI:1720112360
Name:SHELDRAKE, TRACIE LYNN (QMHA)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:LYNN
Last Name:SHELDRAKE
Suffix:
Gender:F
Credentials:QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2255 15TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-1947
Mailing Address - Country:US
Mailing Address - Phone:503-391-6534
Mailing Address - Fax:
Practice Address - Street 1:3180 CENTER ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4532
Practice Address - Country:US
Practice Address - Phone:503-361-2665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health