Healthcare Provider Details

I. General information

NPI: 1366706145
Provider Name (Legal Business Name): MELISSA A TRACY LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA BUSTAMANTE LCPC

II. Dates (important events)

Enumeration Date: 06/27/2012
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5001 COLLEGE BLVD STE 107
LEAWOOD KS
66211-1618
US

IV. Provider business mailing address

5001 COLLEGE BLVD STE 107
LEAWOOD KS
66211-1618
US

V. Phone/Fax

Practice location:
  • Phone: 913-318-4679
  • Fax:
Mailing address:
  • Phone: 913-318-4679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC 2511
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC 2539
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: