Provider Demographics
NPI:1396552774
Name:BOSCH, TRACEE MARIE
Entity type:Individual
Prefix:
First Name:TRACEE
Middle Name:MARIE
Last Name:BOSCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 LABORE RD STE 104
Mailing Address - Street 2:
Mailing Address - City:VADNAIS HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55110-5186
Mailing Address - Country:US
Mailing Address - Phone:612-398-1086
Mailing Address - Fax:
Practice Address - Street 1:3200 LABORE RD STE 104
Practice Address - Street 2:
Practice Address - City:VADNAIS HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55110-5186
Practice Address - Country:US
Practice Address - Phone:612-398-1086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-18
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN156341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical