Healthcare Provider Details

I. General information

NPI: 1780103440
Provider Name (Legal Business Name): TRACY CHARISSE WHARTON PHD, MSC, MED, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2017
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12345 PARKLAWN DR STE 200
ROCKVILLE MD
20852-1725
US

IV. Provider business mailing address

12345 PARKLAWN DR, STE 200 #1061
ROCKVILLE MD
20852-1725
US

V. Phone/Fax

Practice location:
  • Phone: 508-280-8715
  • Fax:
Mailing address:
  • Phone: 508-280-8715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number32755
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3641C
License Number StateAL
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1140807
License Number StateMA
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW12849
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: