Provider Demographics
NPI:1720763758
Name:TRACEY, HEIDI (MA, CAS, LGPC, NCSP)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:TRACEY
Suffix:
Gender:F
Credentials:MA, CAS, LGPC, NCSP
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:
Other - Last Name:TRACEY, LLC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4450 MITCHELLVILLE RD # 1224
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-3112
Mailing Address - Country:US
Mailing Address - Phone:443-808-1531
Mailing Address - Fax:
Practice Address - Street 1:58 MILLHAVEN CT
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:MD
Practice Address - Zip Code:21037-1825
Practice Address - Country:US
Practice Address - Phone:443-808-1531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP12742101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health