Provider Demographics
NPI:1053642645
Name:MULLIAN, TRACEY L (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:L
Last Name:MULLIAN
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:L
Other - Last Name:GONCALVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13823 197TH AVE E
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-5234
Mailing Address - Country:US
Mailing Address - Phone:253-304-7701
Mailing Address - Fax:
Practice Address - Street 1:13823 197TH AVE E
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-5234
Practice Address - Country:US
Practice Address - Phone:253-304-7701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-20
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000094471041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical