Healthcare Provider Details

I. General information

NPI: 1982471611
Provider Name (Legal Business Name): AMANDA TRACEY LGPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2023
Last Update Date: 12/04/2023
Certification Date: 12/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 SOLAREX CT UNIT 201
FREDERICK MD
21703-8655
US

IV. Provider business mailing address

211 CRESTVIEW DR
THURMONT MD
21788-1806
US

V. Phone/Fax

Practice location:
  • Phone: 301-663-8263
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLGP14613
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: