Provider Demographics
NPI:1104059054
Name:ROE, TRACY LYNN (MA, LCPC, NCC)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:ROE
Suffix:
Gender:F
Credentials:MA, LCPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 N BOGUS BASIN RD APT D103
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-0976
Mailing Address - Country:US
Mailing Address - Phone:208-866-3971
Mailing Address - Fax:
Practice Address - Street 1:3350 W AMERICANA TER STE 330C
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-2547
Practice Address - Country:US
Practice Address - Phone:208-866-3971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-26
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18781101Y00000X
IDLCPC-4651101YM0800X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health