Provider Demographics
NPI:1366242679
Name:MOORE, TRACY B
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:B
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:B
Other - Last Name:JIPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1240 BROADWAY N APT 5
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-2660
Mailing Address - Country:US
Mailing Address - Phone:701-561-9081
Mailing Address - Fax:
Practice Address - Street 1:1240 BROADWAY N APT 5
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-2660
Practice Address - Country:US
Practice Address - Phone:701-561-9081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-17
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging