MEDICARE: TRACIE BISHOP

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	104100000X	Social Worker	I.2304748-SUPV	OH
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	CS.00001705	OH
3	101YA0400X	Addiction (Substance Use Disorder) Counselor	LICDC.121005	OH

General Provider Information

NPI Number	:	1912444514
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACIE BISHOP

Provider Business Mailing Address
First Line	:	904 N FOUNTAIN AVE
Second Line	:
City	:	SPRINGFIELD
State	:	OH
Zip	:	45504-2226
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1948 N LIMESTONE ST
Second Line	:
City	:	SPRINGFIELD
State	:	OH
Zip	:	45503-2648
Country	:	US
Telephone Number	:	866-534-2639
Fax Number	:

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

Provider Enumeration Date	:	01/21/2017
Last Update Date	:	09/16/2025

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Directions to “ TRACIE BISHOP ” Practice Location

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