Provider Demographics
NPI:1427758325
Name:WILSON, TRACY LOUISE (LCPCC)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LOUISE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCPCC
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:L
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCPCC
Mailing Address - Street 1:PO BOX 17491
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-7491
Mailing Address - Country:US
Mailing Address - Phone:406-531-1042
Mailing Address - Fax:
Practice Address - Street 1:300 W BROADWAY ST STE 2
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4126
Practice Address - Country:US
Practice Address - Phone:406-531-1042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-08
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT62548101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health