Provider Demographics
NPI:1801678149
Name:GOERNDT, TRACEY ANN (LAC)
Entity type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:ANN
Last Name:GOERNDT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 361
Mailing Address - Street 2:
Mailing Address - City:GLENDIVE
Mailing Address - State:MT
Mailing Address - Zip Code:59330-0361
Mailing Address - Country:US
Mailing Address - Phone:406-377-2072
Mailing Address - Fax:
Practice Address - Street 1:120 W TOWNE ST
Practice Address - Street 2:
Practice Address - City:GLENDIVE
Practice Address - State:MT
Practice Address - Zip Code:59330-1702
Practice Address - Country:US
Practice Address - Phone:406-377-2072
Practice Address - Fax:406-377-2071
Is Sole Proprietor?:No
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBHLACLIC50005101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)