Healthcare Provider Details

I. General information

NPI: 1134164254
Provider Name (Legal Business Name): TRACEY MICHELLE MARK-BOSTON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TRACEY MICHELLE MARK

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 02/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 W CANAL ST
PICAYUNE MS
39466-3918
US

IV. Provider business mailing address

2314 WALKER ST
PICAYUNE MS
39466-3066
US

V. Phone/Fax

Practice location:
  • Phone: 601-749-9477
  • Fax:
Mailing address:
  • Phone: 228-234-2918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC3690
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: