Healthcare Provider Details

I. General information

NPI: 1205311990
Provider Name (Legal Business Name): TRACY EVANS M.A., LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2018
Last Update Date: 09/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

443 KEMPSVILLE RD
NORFOLK VA
23502-4797
US

IV. Provider business mailing address

443 KEMPSVILLE RD
NORFOLK VA
23502-4797
US

V. Phone/Fax

Practice location:
  • Phone: 757-455-6100
  • Fax:
Mailing address:
  • Phone: 757-455-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701007779
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: