Healthcare Provider Details

I. General information

NPI: 1932823929
Provider Name (Legal Business Name): TRACYS RESIDENTIAL RE ENTRY CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1365 DEVONPORT DR
LEXINGTON KY
40504-1552
US

IV. Provider business mailing address

1365 DEVONPORT DR
LEXINGTON KY
40504-1512
US

V. Phone/Fax

Practice location:
  • Phone: 859-309-2240
  • Fax:
Mailing address:
  • Phone: 859-309-2240
  • Fax: 859-800-5261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MISS CHIQUITA SHIELDS
Title or Position: PRESIDENT/DIRECTOR
Credential:
Phone: 859-229-8027