Healthcare Provider Details

I. General information

NPI: 1366804049
Provider Name (Legal Business Name): TRACEY ALTA LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4540 UNION BAY PL NE
SEATTLE WA
98105-4025
US

IV. Provider business mailing address

3616 INTERLAKE AVE N
SEATTLE WA
98103-8105
US

V. Phone/Fax

Practice location:
  • Phone: 206-320-4025
  • Fax: 206-320-8048
Mailing address:
  • Phone: 631-830-1250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLW00009543
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW00009543
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: