Healthcare Provider Details

I. General information

NPI: 1043435944
Provider Name (Legal Business Name): HATTIE M TRACY LISW, LCDCIII
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HATTIE M TRACY-KRAMER LISW,LCDCIII

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 02/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4209 STATE ROUTE 44
ROOTSTOWN OH
44272-9698
US

IV. Provider business mailing address

4209 STATE ROUTE 44
ROOTSTOWN OH
44272-9698
US

V. Phone/Fax

Practice location:
  • Phone: 330-325-6697
  • Fax: 330-325-5970
Mailing address:
  • Phone: 330-325-6697
  • Fax: 330-325-5970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI.0900274
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number081003
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: