Provider Demographics
NPI:1780103440
Name:WHARTON, TRACY CHARISSE (PHD, MSC, MED, LCSW)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:CHARISSE
Last Name:WHARTON
Suffix:
Gender:F
Credentials:PHD, MSC, MED, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:972 TROON TRCE
Mailing Address - Street 2:
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-4318
Mailing Address - Country:US
Mailing Address - Phone:508-280-8715
Mailing Address - Fax:
Practice Address - Street 1:12805 PEGASUS DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32816-8030
Practice Address - Country:US
Practice Address - Phone:407-823-2819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-13
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
AL3641C1041C0700X
FLSW128491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker