Healthcare Provider Details

I. General information

NPI: 1629474093
Provider Name (Legal Business Name): TRACY SHOWANNA FREEMAN LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2014
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 S VAL VISTA DR APT 1091
MESA AZ
85204-6443
US

IV. Provider business mailing address

1440 S VAL VISTA DR APT 1091
MESA AZ
85204-6443
US

V. Phone/Fax

Practice location:
  • Phone: 480-455-7679
  • Fax: 602-599-5704
Mailing address:
  • Phone: 480-455-7679
  • Fax: 602-599-5704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC-24283
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: