Basic Information
| Provider Information | |||||||||
| NPI: | 1376656280 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUNNE | ||||||||
| FirstName: | TRACEY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LISW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11201 ANAHEIM AVE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871221550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058289421 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1501 SAN PEDRO DR SE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871085153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052651711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 12/04/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I-07148 | NM | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | I-07148 | 01 | NM | STATE LICENSE | OTHER | M-2720 | 01 | NM | SOCIAL WORK LICENSE # | OTHER |