Provider Demographics
NPI:1902048820
Name:LICHNER, TRACEY (PHD)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:LICHNER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 4TH AVE SOUTH
Mailing Address - Street 2:SUITE 5010, PMB#93151
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55415-3309
Mailing Address - Country:US
Mailing Address - Phone:612-444-1769
Mailing Address - Fax:
Practice Address - Street 1:310 4TH AVE SOUTH
Practice Address - Street 2:SUITE 5010, PMB#93151
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415-3309
Practice Address - Country:US
Practice Address - Phone:612-444-1769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-25
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5680103T00000X
PAPS016298103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist