Basic Information
| Provider Information | |||||||||
| NPI: | 1467949404 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | TRACEY | ||||||||
| MiddleName: | DEANNE | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 COMMUNITY | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647358804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608858131 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1780 OLD HIGHWAY 50 E STE 113 | ||||||||
| Address2: | |||||||||
| City: | UNION | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6365828100 | ||||||||
| FaxNumber: | 6365832885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2018 | ||||||||
| LastUpdateDate: | 06/22/2018 | ||||||||
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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 | 101YM0800X | 2018011501 | MO | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 2018011501 | MO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.