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NPI Code Detail

MEDICARE: MRS. TRACEY LYNN WHITE LCSW

MEDICARE: MRS. TRACEY LYNN WHITE LCSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker1234AK
21041C0700XClinical Social Worker38434ID

General Provider Information

NPI Number : 1134555782
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. TRACEY LYNN WHITE LCSW
Provider Business Mailing Address
First Line : 2290 W PRAIRIE AVE
Second Line :
City : COEUR D ALENE
State : ID
Zip : 83815-8424
Country : US
Telephone Number : 208-772-7994
Fax Number : 208-772-5916
Provider Business Practice Location Address
First Line : 2290 W PRAIRIE AVE
Second Line :
City : COEUR D ALENE
State : ID
Zip : 83815-8424
Country : US
Telephone Number : 207-772-7994
Fax Number : 208-772-5916
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/15/2013
Last Update Date : 02/21/2022

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