=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063829901
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN ROBERT TRACY LCSW, LISW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2014
-----------------------------------------------------
Last Update Date | 07/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 WILLOW AVE STE 210
-----------------------------------------------------
City | COUNCIL BLUFFS
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51503-0827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-332-4640
-----------------------------------------------------
Fax | 712-322-4643
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 WILLOW AVE STE 210
-----------------------------------------------------
City | COUNCIL BLUFFS
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51503-0827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-332-4640
-----------------------------------------------------
Fax | 712-322-4643
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 1211
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CSW.00991938
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------