Provider Demographics
NPI:1902902323
Name:SHOEMAKER, TRACEY (MA, LP)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:SHOEMAKER
Suffix:
Gender:F
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5600 HOLIDAY RD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-5417
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1485 81ST AVE NE
Practice Address - Street 2:
Practice Address - City:SPRING LAKE PARK
Practice Address - State:MN
Practice Address - Zip Code:55432-2111
Practice Address - Country:US
Practice Address - Phone:763-780-3036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3750103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN62-22415OtherMEDICA
MN5483166-00OtherMA
MN61D95SHOtherBLUE CROSS
MNHP27880OtherHEALTH PARTNERS
MN108248OtherUCARE