Provider Demographics
NPI:1962914424
Name:ANDERSON, TRACY JEROME
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:JEROME
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8526 ELMVIEW PL
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71108-5704
Mailing Address - Country:US
Mailing Address - Phone:318-519-4551
Mailing Address - Fax:
Practice Address - Street 1:543 STONER AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4122
Practice Address - Country:US
Practice Address - Phone:318-673-9901
Practice Address - Fax:318-673-9904
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-24
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1147664Medicaid