1780769216 NPI number — MS. LYNETTE EFFIE TRACY CDP, LICSW

Table of content: MS. LYNETTE EFFIE TRACY CDP, LICSW (NPI 1780769216)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780769216 NPI number — MS. LYNETTE EFFIE TRACY CDP, LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TRACY
Provider First Name:
LYNETTE
Provider Middle Name:
EFFIE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CDP, LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NELSON
Provider Other First Name:
LYNETTE
Provider Other Middle Name:
EFFIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1780769216
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1601 E 4TH PLAIN BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98661-3753
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-397-8246
Provider Business Mailing Address Fax Number:
360-397-8450

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1601 E FOURTH PLAIN BLVD
Provider Second Line Business Practice Location Address:
BLDG 17
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98661-3753
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-397-8246
Provider Business Practice Location Address Fax Number:
360-397-8450
Provider Enumeration Date:
10/25/2006

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: 101YA0400X , with the licence number:  CP00005446 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X , with the licence number: LW 60363996 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 164936 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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