Basic Information
| Provider Information | |||||||||
| NPI: | 1508187865 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | TRACI | ||||||||
| MiddleName: | LEEANN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | LAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MADSEN | ||||||||
| OtherFirstName: | TRACI | ||||||||
| OtherMiddleName: | LEEANN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 715 HORIZON DR STE 225 | ||||||||
| Address2: | |||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815068743 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 515 28 3/4 RD | ||||||||
| Address2: | |||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815015016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702416023 | ||||||||
| FaxNumber: | 9702428330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2010 | ||||||||
| LastUpdateDate: | 07/29/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | ACD.0000247 | CO | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | LPC.0015275 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.