Provider Demographics
NPI:1528255585
Name:BREN-CLEGG, TRACIE ERIN (LPC-MH)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:ERIN
Last Name:BREN-CLEGG
Suffix:
Gender:F
Credentials:LPC-MH
Other - Prefix:
Other - First Name:TRACIE
Other - Middle Name:ERIN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC-MH
Mailing Address - Street 1:611 DAHL RD STE 8
Mailing Address - Street 2:
Mailing Address - City:SPEARFISH
Mailing Address - State:SD
Mailing Address - Zip Code:57783-2739
Mailing Address - Country:US
Mailing Address - Phone:605-641-7534
Mailing Address - Fax:
Practice Address - Street 1:611 DAHL RD STE 8
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-2739
Practice Address - Country:US
Practice Address - Phone:605-641-7534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-03
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLPC-MH20366101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health