MEDICARE: TRACY HANNAH

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
1	101YM0800X	Mental Health Counselor	MH11852	FL

General Provider Information

NPI Number	:	1265821870
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACY HANNAH

Provider Business Mailing Address
First Line	:	6000A SAWGRASS VILLAGE CIR
Second Line	:
City	:	PONTE VEDRA
State	:	FL
Zip	:	32082-5011
Country	:	US
Telephone Number	:	443-831-7230
Fax Number	:

Provider Business Practice Location Address
First Line	:	6000A SAWGRASS VILLAGE CIR
Second Line	:
City	:	PONTE VEDRA
State	:	FL
Zip	:	32082-5011
Country	:	US
Telephone Number	:	443-831-7230
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2015
Last Update Date	:	01/20/2015

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