Provider Demographics
NPI:1932750064
Name:GALLOWAY, TRACEY ELIZABETH (LSSP, LPC)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:ELIZABETH
Last Name:GALLOWAY
Suffix:
Gender:F
Credentials:LSSP, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15322 COUNTY ROAD 472
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75706-4032
Mailing Address - Country:US
Mailing Address - Phone:903-413-3898
Mailing Address - Fax:
Practice Address - Street 1:13359 HWY 155 S
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-6554
Practice Address - Country:US
Practice Address - Phone:903-413-3898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-20
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68245101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional