Provider Demographics
NPI:1902861974
Name:WHITAKER, TRACY LEE (LCSW)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LEE
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 835
Mailing Address - Street 2:
Mailing Address - City:FLOYD
Mailing Address - State:VA
Mailing Address - Zip Code:24091-0835
Mailing Address - Country:US
Mailing Address - Phone:540-745-9290
Mailing Address - Fax:540-745-9293
Practice Address - Street 1:140 CHRISTIANSBURG PIKE NE
Practice Address - Street 2:
Practice Address - City:FLOYD
Practice Address - State:VA
Practice Address - Zip Code:24091-3742
Practice Address - Country:US
Practice Address - Phone:540-745-9290
Practice Address - Fax:540-745-9293
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040060971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004945115Medicaid
VA180716OtherHEALTHKEEPERS
VA180716Medicaid
VAO85302MOtherSOUTHERN HEALTH
VA180716OtherANTHEM
VAO85302MMedicaid
VAO85302MOtherSOUTHERN HEALTH
VA008290M13Medicare ID - Type UnspecifiedMEDICARE