Healthcare Provider Details

I. General information

NPI: 1659512234
Provider Name (Legal Business Name): TRACY RENEE GRANT BA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2009
Last Update Date: 03/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 MAIN ST E
MENOMONIE WI
54751-2735
US

IV. Provider business mailing address

808 MAIN ST E
MENOMONIE WI
54751-2735
US

V. Phone/Fax

Practice location:
  • Phone: 715-232-1116
  • Fax: 715-232-5987
Mailing address:
  • Phone: 715-232-1116
  • Fax: 715-232-5987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: