Provider Demographics
NPI:1063605749
Name:JOHNSON, TRACEY E
Entity type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2304 ROGATE CIR
Mailing Address - Street 2:303
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21244-5736
Mailing Address - Country:US
Mailing Address - Phone:410-944-0276
Mailing Address - Fax:
Practice Address - Street 1:2304 ROGATE CIR
Practice Address - Street 2:303
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21244-5736
Practice Address - Country:US
Practice Address - Phone:410-944-0276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-25
Last Update Date:2007-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC1655101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional