Provider Demographics
NPI:1699957704
Name:ELAM, TRACY JEWELL (LCSW)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:JEWELL
Last Name:ELAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 690
Mailing Address - Street 2:
Mailing Address - City:BEATTYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41311-0690
Mailing Address - Country:US
Mailing Address - Phone:606-464-0151
Mailing Address - Fax:606-464-0152
Practice Address - Street 1:905 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST LIBERTY
Practice Address - State:KY
Practice Address - Zip Code:41472-1023
Practice Address - Country:US
Practice Address - Phone:606-743-4808
Practice Address - Fax:606-743-4716
Is Sole Proprietor?:No
Enumeration Date:2007-11-30
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2522441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY252244OtherLCSW LICENSURE
KY7100499630Medicaid