Provider Demographics
NPI:1912444514
Name:BISHOP, TRACIE
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:BISHOP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 N FOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504-2226
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1948 N LIMESTONE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-2648
Practice Address - Country:US
Practice Address - Phone:866-534-2639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-21
Last Update Date:2025-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.2304748-SUPV104100000X
OHCS.00001705101YA0400X
OHLICDC.121005101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)