Healthcare Provider Details

I. General information

NPI: 1043544471
Provider Name (Legal Business Name): TRACY P SMITH MA LICENSED PSYCHOLOGIST PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2009
Last Update Date: 06/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 CHEROKEE TRL
ELKVIEW WV
25071-9263
US

IV. Provider business mailing address

1511 RAMBLER RD
CHARLESTON WV
25314-1830
US

V. Phone/Fax

Practice location:
  • Phone: 304-965-0372
  • Fax: 304-965-0372
Mailing address:
  • Phone: 304-539-6222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number785
License Number StateWV

VIII. Authorized Official

Name: MS. TRACY PAULEY SMITH
Title or Position: LICENSED PSYCHOLOGIST/OWNER
Credential: MA
Phone: 304-539-6222