1699106260 NPI number — TRACY WICK MA, LPC

Table of content: TRACY WICK MA, LPC (NPI 1699106260)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699106260 NPI number — TRACY WICK MA, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WICK
Provider First Name:
TRACY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, LPC
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:
1699106260
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1401 E 1ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55805-2407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-728-4491
Provider Business Mailing Address Fax Number:
218-728-4404

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 N 34TH ST
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
SUPERIOR
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54880-4477
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-392-8216
Provider Business Practice Location Address Fax Number:
715-392-6055
Provider Enumeration Date:
12/09/2013

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: 101YP2500X , with the licence number:  5893-125 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101Y00000X , with the licence number: 1966-226 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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