Basic Information
| Provider Information | |||||||||
| NPI: | 1003255696 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDONALD | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | LPCC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNS | ||||||||
| OtherFirstName: | TRACY | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 177 LES GILREATH ROAD | ||||||||
| Address2: | |||||||||
| City: | STEARNS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42647 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 90 MEDICAL LN | ||||||||
| Address2: | |||||||||
| City: | WHITLEY CITY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 426534216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063762466 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2013 | ||||||||
| LastUpdateDate: | 05/11/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 239923 | KY | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.