Provider Demographics
NPI:1588052393
Name:TRACY BRYCE FARMER LCSW PC
Entity type:Organization
Organization Name:TRACY BRYCE FARMER LCSW PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYCE FARMER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, MFA, CADC
Authorized Official - Phone:503-451-3267
Mailing Address - Street 1:1020 SW TAYLOR ST
Mailing Address - Street 2:SUITE 435
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2543
Mailing Address - Country:US
Mailing Address - Phone:503-841-2722
Mailing Address - Fax:541-668-8013
Practice Address - Street 1:1020 SW TAYLOR ST
Practice Address - Street 2:SUITE 435
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2543
Practice Address - Country:US
Practice Address - Phone:503-841-2722
Practice Address - Fax:541-668-8013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-31
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
OR56791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR184784Medicare UPIN