Healthcare Provider Details

I. General information

NPI: 1124168877
Provider Name (Legal Business Name): TRACEY L JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 09/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6009 SQUIRE CT #1
MEMPHIS TN
38115-3226
US

IV. Provider business mailing address

2946 COVINGTON PIKE PMB 162
MEMPHIS TN
38128-6007
US

V. Phone/Fax

Practice location:
  • Phone: 901-396-9007
  • Fax:
Mailing address:
  • Phone: 901-396-9007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number61252
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2331
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: