Healthcare Provider Details

I. General information

NPI: 1831478106
Provider Name (Legal Business Name): TRACIE ELAINE SIDES LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2011
Last Update Date: 07/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56 N 2ND ST
MACCLENNY FL
32063-2206
US

IV. Provider business mailing address

4300 SW 13TH STREET
GAINESVILLE FL
32608-4006
US

V. Phone/Fax

Practice location:
  • Phone: 904-259-0264
  • Fax:
Mailing address:
  • Phone: 352-374-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH9608
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: