Provider Demographics
NPI:1316378185
Name:BROTHERS, TRACY LAUREL (LCPC)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:LAUREL
Last Name:BROTHERS
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3255 LT. MOSS ROAD
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7298
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1305 WYOMING STREET
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804
Practice Address - Country:US
Practice Address - Phone:506-532-9770
Practice Address - Fax:406-541-3034
Is Sole Proprietor?:No
Enumeration Date:2013-12-04
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4780101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional