Basic Information
| Provider Information | |||||||||
| NPI: | 1598304453 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5701 THURSTON AVE STE 103 | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234553331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573403489 | ||||||||
| FaxNumber: | 7873404278 | ||||||||
| Practice Location | |||||||||
| Address1: | 707 GUM ROCK CT | ||||||||
| Address2: | |||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236062523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7578732273 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/24/2019 | ||||||||
| LastUpdateDate: | 02/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 0701008733 | VA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.