Provider Demographics
NPI:1245444058
Name:PARKS, TRACY RYAN (LPC)
Entity type:Individual
Prefix:MR
First Name:TRACY
Middle Name:RYAN
Last Name:PARKS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32728 STATE HWY E
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:MO
Mailing Address - Zip Code:63549-5156
Mailing Address - Country:US
Mailing Address - Phone:660-341-0552
Mailing Address - Fax:
Practice Address - Street 1:1611 S BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-4536
Practice Address - Country:US
Practice Address - Phone:660-665-7575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003013757101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health