Healthcare Provider Details

I. General information

NPI: 1760936280
Provider Name (Legal Business Name): TRACY ANN SANNA LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2016
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 DULANEY VALLEY RD
TOWSON MD
21204
US

IV. Provider business mailing address

122 ROCHESTER PL
BALTIMORE MD
21224-2258
US

V. Phone/Fax

Practice location:
  • Phone: 104-567-1117
  • Fax:
Mailing address:
  • Phone: 302-229-5806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC10642
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGP5846
License Number StateMD

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: