Provider Demographics
NPI:1831742741
Name:BAUSTERT, TRACY M
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:M
Last Name:BAUSTERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17250 N SHEPARD AVE
Mailing Address - Street 2:
Mailing Address - City:OKARCHE
Mailing Address - State:OK
Mailing Address - Zip Code:73762-2058
Mailing Address - Country:US
Mailing Address - Phone:405-226-1798
Mailing Address - Fax:
Practice Address - Street 1:1600 E HWY 66
Practice Address - Street 2:EL RENO
Practice Address - City:OKLAHOMA
Practice Address - State:OK
Practice Address - Zip Code:73036
Practice Address - Country:US
Practice Address - Phone:405-226-1798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-19
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OK101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator