Provider Demographics
NPI:1427807627
Name:BIRDSELL, TRACI L (PHD)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:L
Last Name:BIRDSELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3415 7TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4903
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:312 MILLER ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-1944
Practice Address - Country:US
Practice Address - Phone:208-750-1802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-18
Last Update Date:2024-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-45152104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker