Provider Demographics
NPI:1346743358
Name:TRACE, ASHLEY METRONUS (LCSW)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:METRONUS
Last Name:TRACE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 S MANITOU AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-4148
Mailing Address - Country:US
Mailing Address - Phone:503-280-1385
Mailing Address - Fax:
Practice Address - Street 1:3330 E LOUISE DR STE 400
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5123
Practice Address - Country:US
Practice Address - Phone:208-513-3451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-15
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-450321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical