Provider Demographics
NPI:1063750016
Name:KOTVAL, TRACY (MA, LPCC)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:KOTVAL
Suffix:
Gender:F
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:KLING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10535 165TH ST W
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-5729
Mailing Address - Country:US
Mailing Address - Phone:612-787-2297
Mailing Address - Fax:
Practice Address - Street 1:10535 165TH ST W
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-5729
Practice Address - Country:US
Practice Address - Phone:612-787-2297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-26
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN01256101YM0800X
MNCC00605101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health