Healthcare Provider Details

I. General information

NPI: 1407859465
Provider Name (Legal Business Name): TRACIE L ANDERSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 08/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 SPRING ST
JEFFERSONVILLE IN
47130-3554
US

IV. Provider business mailing address

510 SPRING ST
JEFFERSONVILLE IN
47130-3554
US

V. Phone/Fax

Practice location:
  • Phone: 812-282-1888
  • Fax: 812-218-9318
Mailing address:
  • Phone: 812-282-1888
  • Fax: 812-218-9318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34000315A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number807
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: