Provider Demographics
NPI:1053531855
Name:MARTIN, TRACY LEA
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LEA
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 S HARRILL
Mailing Address - Street 2:ERI
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467
Mailing Address - Country:US
Mailing Address - Phone:918-485-3554
Mailing Address - Fax:918-485-8371
Practice Address - Street 1:109 S HARRILL
Practice Address - Street 2:ERI
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467
Practice Address - Country:US
Practice Address - Phone:918-485-3554
Practice Address - Fax:918-485-8371
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor