Provider Demographics
NPI:1144897604
Name:PEDERSON, TRACY
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:865 WILLOW BROOK TRL
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-3454
Mailing Address - Country:US
Mailing Address - Phone:608-318-0086
Mailing Address - Fax:
Practice Address - Street 1:2021 ATWOOD AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-5324
Practice Address - Country:US
Practice Address - Phone:608-244-4859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8875-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical