Provider Demographics
NPI:1912168790
Name:MINERVINO, TRACEY LEE (LCSW)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:LEE
Last Name:MINERVINO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 N MAIN ST STE 203
Mailing Address - Street 2:
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-2055
Mailing Address - Country:US
Mailing Address - Phone:207-907-4343
Mailing Address - Fax:207-907-4343
Practice Address - Street 1:141 N MAIN ST STE 203
Practice Address - Street 2:
Practice Address - City:BREWER
Practice Address - State:ME
Practice Address - Zip Code:04412-2055
Practice Address - Country:US
Practice Address - Phone:207-907-4343
Practice Address - Fax:207-907-4343
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-24
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC132551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical