Provider Demographics
NPI:1134164254
Name:MARK-BOSTON, TRACEY MICHELLE (LCSW)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:MICHELLE
Last Name:MARK-BOSTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:MICHELLE
Other - Last Name:MARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2314 WALKER ST
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-3066
Mailing Address - Country:US
Mailing Address - Phone:228-234-2918
Mailing Address - Fax:
Practice Address - Street 1:703 W CANAL ST
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-3918
Practice Address - Country:US
Practice Address - Phone:601-749-9477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC3690101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health