Provider Demographics
NPI:1124685870
Name:SUNDE, TRACY L (LADC)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:SUNDE
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 4TH ST SW
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MN
Mailing Address - Zip Code:55049-9568
Mailing Address - Country:US
Mailing Address - Phone:507-210-8695
Mailing Address - Fax:
Practice Address - Street 1:512 4TH ST SW
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MN
Practice Address - Zip Code:55049-9568
Practice Address - Country:US
Practice Address - Phone:507-210-8695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305441101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)