=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215177084
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACY W DEAGAN LPS-S, LCSW-S
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2009
-----------------------------------------------------
Last Update Date | 03/05/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 907 W MARY ST
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78704-4141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-796-3457
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 907 W MARY ST
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78704-4141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-796-3457
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 12011
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 19860 LCSW-S
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------