Provider Demographics
NPI:1720352784
Name:MAIN, TRACY LYNN (LPC)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:LYNN
Last Name:MAIN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 MEADOWS RD
Mailing Address - Street 2:
Mailing Address - City:POTEET
Mailing Address - State:TX
Mailing Address - Zip Code:78065-4874
Mailing Address - Country:US
Mailing Address - Phone:210-384-1254
Mailing Address - Fax:
Practice Address - Street 1:18838 STONE OAK PKWY STE 201
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4179
Practice Address - Country:US
Practice Address - Phone:210-384-1254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74070101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty