Provider Demographics
NPI:1740698471
Name:ADEVAI, TRACY RENEE (LCSW)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:RENEE
Last Name:ADEVAI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:COLLIDNG RIVERS
Other - Middle Name:COUNSELING
Other - Last Name:SERVICES, LLC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 375
Mailing Address - Street 2:
Mailing Address - City:GLIDE
Mailing Address - State:OR
Mailing Address - Zip Code:97443-0375
Mailing Address - Country:US
Mailing Address - Phone:541-671-5185
Mailing Address - Fax:541-230-2575
Practice Address - Street 1:285 SE FOWLER ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3337
Practice Address - Country:US
Practice Address - Phone:541-671-5185
Practice Address - Fax:541-230-2575
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-25
Last Update Date:2024-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORL108991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500685947Medicaid