Provider Demographics
NPI:1104601723
Name:KRISCHIK, TRACI ANN
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:ANN
Last Name:KRISCHIK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11401 MENAUL BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-2435
Mailing Address - Country:US
Mailing Address - Phone:505-526-3649
Mailing Address - Fax:
Practice Address - Street 1:11401 MENAUL BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-2435
Practice Address - Country:US
Practice Address - Phone:505-525-3649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-30
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCCSS175T00000X
NMCTB-2025-0146101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist