1922330968 NPI number — MRS. TRACEY ARLENE BOUBACAR MS,MSW,LCSW

Table of content: MRS. TRACEY ARLENE BOUBACAR MS,MSW,LCSW (NPI 1922330968)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922330968 NPI number — MRS. TRACEY ARLENE BOUBACAR MS,MSW,LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOUBACAR
Provider First Name:
TRACEY
Provider Middle Name:
ARLENE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS,MSW,LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922330968
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
284 EXECUTIVE PARK DR
Provider Second Line Business Mailing Address:
SUITE100
Provider Business Mailing Address City Name:
CONCORD
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28025-1831
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-939-1100
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
405 NC HWY 65
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REIDSVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27320-8882
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-342-8316
Provider Business Practice Location Address Fax Number:
336-342-8352
Provider Enumeration Date:
02/01/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  C005729 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)