Healthcare Provider Details

I. General information

NPI: 1346557402
Provider Name (Legal Business Name): TRACY STUBBLEFIELD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2010
Last Update Date: 11/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9701 APOLLO DR SUITE 441
LARGO MD
20774-4783
US

IV. Provider business mailing address

4630 HAYES STREET NE
WASHINGTON DC
20019-3611
US

V. Phone/Fax

Practice location:
  • Phone: 240-764-6892
  • Fax: 240-764-6741
Mailing address:
  • Phone: 240-764-6892
  • Fax: 240-764-6741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number15332
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier15332
Identifier TypeOTHER
Identifier StateMD
Identifier IssuerLICENSE # 15332

VIII. Authorized Official

Name: MS. TRACY R STUBBLEFIELD
Title or Position: LCSW-C
Credential: MSW
Phone: 240-764-6892