Provider Demographics
NPI:1124273115
Name:ROBERTI, TRACY (LCSW)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:ROBERTI
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:PO BOX 3488
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-0317
Mailing Address - Country:US
Mailing Address - Phone:541-621-1415
Mailing Address - Fax:
Practice Address - Street 1:526 NW 21ST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1157
Practice Address - Country:US
Practice Address - Phone:541-621-1415
Practice Address - Fax:541-787-4908
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-18
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR42371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical