Provider Demographics
NPI:1073824389
Name:WILLIAMS, TRACEY LYNNE
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:LYNNE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:LYNNE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1832
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-8131
Mailing Address - Country:US
Mailing Address - Phone:564-218-6367
Mailing Address - Fax:
Practice Address - Street 1:3613 PACIFIC WAY
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-5326
Practice Address - Country:US
Practice Address - Phone:564-218-6367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-01
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2821101YM0800X
WA60173003101YM0800X
WALH60173003101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health