Provider Demographics
NPI:1881174506
Name:MARTIN, TRACIE JUANETTE
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:JUANETTE
Last Name:MARTIN
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 1:8440 N SAM HOUSTON PKWY E APT 1326
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77396-2980
Mailing Address - Country:US
Mailing Address - Phone:409-543-3300
Mailing Address - Fax:
Practice Address - Street 1:8440 N SAM HOUSTON PKWY E APT 1326
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77396-2980
Practice Address - Country:US
Practice Address - Phone:409-543-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5630OtherCOMMUNITY HEALTH WORKER