Healthcare Provider Details

I. General information

NPI: 1609052596
Provider Name (Legal Business Name): TRACY ROSE BIRMINGHAM LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACY ROSE BOOTH

II. Dates (important events)

Enumeration Date: 01/10/2008
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 W KEISER AVE
OSCEOLA AR
72370-3467
US

IV. Provider business mailing address

1815 PLEASANT GROVE RD
JONESBORO AR
72405-7870
US

V. Phone/Fax

Practice location:
  • Phone: 870-622-0592
  • Fax: 870-336-1339
Mailing address:
  • Phone: 870-933-6886
  • Fax: 870-336-1339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: