Healthcare Provider Details

I. General information

NPI: 1073015087
Provider Name (Legal Business Name): TRACY DEANN VACCA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2018
Last Update Date: 03/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2549 CHARLOTTE ST
KANSAS CITY MO
64108-2735
US

IV. Provider business mailing address

2549 CHARLOTTE ST
KANSAS CITY MO
64108-2735
US

V. Phone/Fax

Practice location:
  • Phone: 816-914-6953
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2015044121
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2015044121
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: