1336594258 NPI number — TRACEY FRAY LCSW

Table of content: (NPI 1336594258)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336594258 NPI number — TRACEY FRAY LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRACEY FRAY LCSW
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1336594258
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29184 ORANGEWOOD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUNTA GORDA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33982-8557
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-824-8516
Provider Business Mailing Address Fax Number:
941-343-2743

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5104 N LOCKWOOD RIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SARASOTA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34234-3311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-824-8516
Provider Business Practice Location Address Fax Number:
941-343-2743
Provider Enumeration Date:
04/28/2016

Additional Information

Authorized Official

Authorized Official Last Name:
FRAY
Authorized Official First Name:
TRACEY
Authorized Official Middle Name:
Authorized Official Title or Position:
LCSW
Authorized Official Telephone Number:
810-824-8516

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  SW 117445 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: SW 11745 . This is a "LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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