Healthcare Provider Details

I. General information

NPI: 1265346696
Provider Name (Legal Business Name): TRACI FUGLESTAD
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 W LOWDER ST
MACCLENNY FL
32063-2638
US

IV. Provider business mailing address

4300 SW 13TH ST
GAINESVILLE FL
32608-4006
US

V. Phone/Fax

Practice location:
  • Phone: 352-374-5600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSW26623
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW26623
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: