Provider Demographics
NPI:1417702333
Name:CHRISTIANSON, TRACIE (LADC)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:CHRISTIANSON
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3162 90TH AVE
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MN
Mailing Address - Zip Code:55371-6134
Mailing Address - Country:US
Mailing Address - Phone:763-220-5483
Mailing Address - Fax:763-220-3969
Practice Address - Street 1:3162 90TH AVE
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MN
Practice Address - Zip Code:55371-6134
Practice Address - Country:US
Practice Address - Phone:763-220-5483
Practice Address - Fax:763-220-3969
Is Sole Proprietor?:No
Enumeration Date:2024-04-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN306878101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)