Basic Information
| Provider Information | |||||||||
| NPI: | 1174281596 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLDER | ||||||||
| FirstName: | TRACEY | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2338 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | DREXEL HILL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190261510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2674671560 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 E LANCASTER AVE STE B-11 | ||||||||
| Address2: | |||||||||
| City: | WYNNEWOOD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190963450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4844762658 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2021 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CW017775 | PA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.