1568425627 NPI number — TRACY L. ROSS-FARES LCSW, C-ASWCM

Table of content: TRACY L. ROSS-FARES LCSW, C-ASWCM (NPI 1568425627)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568425627 NPI number — TRACY L. ROSS-FARES LCSW, C-ASWCM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSS-FARES
Provider First Name:
TRACY
Provider Middle Name:
L.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW, C-ASWCM
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:
1568425627
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2080 CHILD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32214-5005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-270-4294
Provider Business Mailing Address Fax Number:
904-270-4457

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2104 MASSEY AVENUE
Provider Second Line Business Practice Location Address:
NAVAL STATION, MAYPORT
Provider Business Practice Location Address City Name:
MAYPORT
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-270-4294
Provider Business Practice Location Address Fax Number:
904-270-4457
Provider Enumeration Date:
04/10/2006

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: 104100000X , with the licence number:  SW 4952 , 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)





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