Provider Demographics
NPI:1992132336
Name:TRACEY-WINICKI, DIANNE (LMFT)
Entity type:Individual
Prefix:
First Name:DIANNE
Middle Name:
Last Name:TRACEY-WINICKI
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 SKYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06415-2439
Mailing Address - Country:US
Mailing Address - Phone:860-336-6390
Mailing Address - Fax:
Practice Address - Street 1:4 BLONDERS BLVD
Practice Address - Street 2:
Practice Address - City:LEDYARD
Practice Address - State:CT
Practice Address - Zip Code:06339-1504
Practice Address - Country:US
Practice Address - Phone:860-464-9255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000787106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist