Provider Demographics
NPI:1063600302
Name:ERICSON, TRACY ANNE (LCSW)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:ANNE
Last Name:ERICSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:TRACY
Other - Middle Name:A
Other - Last Name:CARRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7 DOCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17842-8910
Mailing Address - Country:US
Mailing Address - Phone:570-837-2123
Mailing Address - Fax:570-837-2185
Practice Address - Street 1:9627 ROUTE 35
Practice Address - Street 2:
Practice Address - City:MT PLEASANT MILLS
Practice Address - State:PA
Practice Address - Zip Code:17853-8409
Practice Address - Country:US
Practice Address - Phone:570-539-2561
Practice Address - Fax:570-539-2702
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-11
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0203821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1034300800002Medicaid
PA6W5479OtherMEDICARE