Basic Information
Provider Information | |||||||||
NPI: | 1699157867 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CROSS | ||||||||
FirstName: | TRACY | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1307 FEDERAL ST STE B100 | ||||||||
Address2: |   | ||||||||
City: | PITTSBURGH | ||||||||
State: | PA | ||||||||
PostalCode: | 152124761 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4123598900 | ||||||||
FaxNumber: | 4123598977 | ||||||||
Practice Location | |||||||||
Address1: | 1307 FEDERAL ST STE B100 | ||||||||
Address2: |   | ||||||||
City: | PITTSBURGH | ||||||||
State: | PA | ||||||||
PostalCode: | 152124761 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4123598900 | ||||||||
FaxNumber: | 4123598977 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/24/2015 | ||||||||
LastUpdateDate: | 11/16/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/16/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | PC009806 | PA | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | PC009806 | PA | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | PC009806 | PA | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | 14084174 | 01 |   | CAQH | OTHER |