1558321265 NPI number — DR. TRACY WILSON LEE PSYD

Table of content: DR. TRACY WILSON LEE PSYD (NPI 1558321265)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558321265 NPI number — DR. TRACY WILSON LEE PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEE
Provider First Name:
TRACY
Provider Middle Name:
WILSON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BEMISTER
Provider Other First Name:
TRACY
Provider Other Middle Name:
LEE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PSYD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1558321265
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
328 CHATHAM RD
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43214-3316
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-456-9842
Provider Business Mailing Address Fax Number:
614-456-9842

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130 NORTHWOODS BLVD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43235-7473
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-456-9842
Provider Business Practice Location Address Fax Number:
614-456-9842
Provider Enumeration Date:
03/25/2006

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: 103T00000X , with the licence number:  6534 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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