MEDICARE: MR. TRACY RYAN PARKS LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	2003013757	MO
2	101YP2500X	Professional Counselor	2003013757	MO

General Provider Information

NPI Number	:	1245444058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TRACY RYAN PARKS LPC

Provider Business Mailing Address
First Line	:	32728 STATE HWY E
Second Line	:
City	:	LA PLATA
State	:	MO
Zip	:	63549-5156
Country	:	US
Telephone Number	:	660-341-0552
Fax Number	:

Provider Business Practice Location Address
First Line	:	1611 S BALTIMORE ST
Second Line	:
City	:	KIRKSVILLE
State	:	MO
Zip	:	63501-4536
Country	:	US
Telephone Number	:	660-665-7575
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/10/2007
Last Update Date	:	04/08/2024

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