Provider Demographics
NPI:1275201725
Name:FAWVER, TRACY R (LCSW)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:R
Last Name:FAWVER
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 1:9577 OSUNA RD NE STE B
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-2286
Mailing Address - Country:US
Mailing Address - Phone:505-238-3345
Mailing Address - Fax:
Practice Address - Street 1:5345 WYOMING BLVD NE STE 107
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3193
Practice Address - Country:US
Practice Address - Phone:505-238-3345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-11646104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker