Provider Demographics
NPI:1912520065
Name:KING, TRACEY (PSYD)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:726 E MAIN ST STE F210
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-1900
Mailing Address - Country:US
Mailing Address - Phone:513-800-1270
Mailing Address - Fax:
Practice Address - Street 1:726 E MAIN ST STE F210
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-1900
Practice Address - Country:US
Practice Address - Phone:513-800-1270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-24
Last Update Date:2023-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHP.07970103T00000X, 106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist