Provider Demographics
NPI:1194150037
Name:STEWART, TRACIE JENNIFER (MS, LPC)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:JENNIFER
Last Name:STEWART
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 W BROWN DEER RD STE A
Mailing Address - Street 2:
Mailing Address - City:BROWN DEER
Mailing Address - State:WI
Mailing Address - Zip Code:53209-1220
Mailing Address - Country:US
Mailing Address - Phone:414-465-8101
Mailing Address - Fax:414-448-6944
Practice Address - Street 1:3900 W BROWN DEER RD
Practice Address - Street 2:SUITE A, PMB 117
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53209
Practice Address - Country:US
Practice Address - Phone:414-465-8101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-11
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5793-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1194150037Medicaid