Provider Demographics
NPI:1215074208
Name:ARRUDA-TRACY, STACEY (LICSW)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:ARRUDA-TRACY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 ATWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02919-3223
Mailing Address - Country:US
Mailing Address - Phone:401-553-1031
Mailing Address - Fax:401-454-0148
Practice Address - Street 1:249 ROOSEVELT AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-2134
Practice Address - Country:US
Practice Address - Phone:401-724-8400
Practice Address - Fax:401-365-1100
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICSW008711041C0700X
RIISW018911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI30343OtherBLUE CROSS CRISIS
RISA56205Medicaid
007057907Medicare PIN