Basic Information
| Provider Information | |||||||||
| NPI: | 1992831366 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITESIDE | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LPCC-S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 252 FOX RIDGE CIR | ||||||||
| Address2: | |||||||||
| City: | POWELL | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430659486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144593003 | ||||||||
| FaxNumber: | 6144593004 | ||||||||
| Practice Location | |||||||||
| Address1: | 1115 BETHEL RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432202690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144593003 | ||||||||
| FaxNumber: | 6144593004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 08/28/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | E4267 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.