Provider Demographics
NPI:1528323334
Name:TRACY W CORBETT, LCSW, PC
Entity type:Organization
Organization Name:TRACY W CORBETT, LCSW, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:WOSKE
Authorized Official - Last Name:CORBETT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:229-460-0663
Mailing Address - Street 1:1013 CHERRY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-5922
Mailing Address - Country:US
Mailing Address - Phone:229-460-0663
Mailing Address - Fax:
Practice Address - Street 1:1013 CHERRY CREEK DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-5922
Practice Address - Country:US
Practice Address - Phone:229-460-0663
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-08
Last Update Date:2012-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0028251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11733902OtherCAQH
GA11733902OtherCAQH