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General NPI Number Information
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NPI Number | 1780103440
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Entity Type | Individual
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Provider Name | TRACY CHARISSE WHARTON PHD, MSC, MED, LCSW
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Gender | Female
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Dates
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Enumeration Date | 09/13/2017
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Last Update Date | 09/13/2017
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Provider Practice Location Address
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Address Line | 12805 PEGASUS DR
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City | ORLANDO
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State | FL
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Zip | 32816-8030
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Country | US
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Telephone | 407-823-2819
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Fax |
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Provider Business Mailing Address
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Address Line | 972 TROON TRCE
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City | WINTER SPRINGS
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State | FL
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Zip | 32708-4318
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Country | US
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Telephone | 508-280-8715
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 3641C
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License Number State | AL
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | SW12849
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License Number State | FL
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