Provider Demographics
NPI:1104572288
Name:MERRIAM, TRACY ANN (LCSW)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:ANN
Last Name:MERRIAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2099
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:
Practice Address - Street 1:110 10TH ST SE
Practice Address - Street 2:
Practice Address - City:BANDON
Practice Address - State:OR
Practice Address - Zip Code:97411-9157
Practice Address - Country:US
Practice Address - Phone:541-347-5191
Practice Address - Fax:541-266-4578
Is Sole Proprietor?:No
Enumeration Date:2022-02-26
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR34201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical