Provider Demographics
NPI:1881178606
Name:RAWLS, TRACY (LIDCD)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:RAWLS
Suffix:
Gender:F
Credentials:LIDCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11134 LUSCHEK DR
Mailing Address - Street 2:
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45241-2434
Mailing Address - Country:US
Mailing Address - Phone:513-827-9273
Mailing Address - Fax:513-818-9960
Practice Address - Street 1:11134 LUSCHEK DR
Practice Address - Street 2:
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45241-2434
Practice Address - Country:US
Practice Address - Phone:513-827-9273
Practice Address - Fax:513-818-9960
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH104100000X
OH081158101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH081158OtherCHEMICAL DEPENDENCY