Healthcare Provider Details

I. General information

NPI: 1790448173
Provider Name (Legal Business Name): TRACY FEY BLACKSTONE MS, CRC, LPC, ASDCS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2021
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2940 CHAPEL VALLEY RD STE 2
FITCHBURG WI
53711-6451
US

IV. Provider business mailing address

901 S WHITNEY WAY
MADISON WI
53711-2553
US

V. Phone/Fax

Practice location:
  • Phone: 608-504-3600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number10458125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: