Provider Demographics
NPI:1285404640
Name:KENWORTHY, TRACEY LATIMORE (PHD)
Entity type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:LATIMORE
Last Name:KENWORTHY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:GEORGIANNA
Other - Last Name:LATIMORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:108 TYLER DR.
Mailing Address - Street 2:
Mailing Address - City:COATESVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19320-2109
Mailing Address - Country:US
Mailing Address - Phone:302-615-1996
Mailing Address - Fax:484-786-4796
Practice Address - Street 1:160 COWAN RD
Practice Address - Street 2:
Practice Address - City:PARKESBURG
Practice Address - State:PA
Practice Address - Zip Code:19365-2109
Practice Address - Country:US
Practice Address - Phone:302-428-9487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS019219103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist