Healthcare Provider Details

I. General information

NPI: 1912444514
Provider Name (Legal Business Name): TRACIE BISHOP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2017
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1948 N LIMESTONE ST
SPRINGFIELD OH
45503-2648
US

IV. Provider business mailing address

904 N FOUNTAIN AVE
SPRINGFIELD OH
45504-2226
US

V. Phone/Fax

Practice location:
  • Phone: 866-534-2639
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI.2304748-SUPV
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCS.00001705
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.121005
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: