Healthcare Provider Details

I. General information

NPI: 1609686013
Provider Name (Legal Business Name): TRACY LEE HARBUCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2025
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 N WASHINGTON AVE STE B
ROSWELL NM
88201-8222
US

IV. Provider business mailing address

111 E 22ND ST APT 110
ROSWELL NM
88201-6436
US

V. Phone/Fax

Practice location:
  • Phone: 575-755-6200
  • Fax:
Mailing address:
  • Phone: 575-291-5613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: