Provider Demographics
NPI:1538276902
Name:ENGSTROM, TRACIE L (LISW)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:L
Last Name:ENGSTROM
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 E SIXTH ST
Mailing Address - Street 2:STE 102
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010
Mailing Address - Country:US
Mailing Address - Phone:515-451-3015
Mailing Address - Fax:
Practice Address - Street 1:103 E SIXTH ST
Practice Address - Street 2:STE 102
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010
Practice Address - Country:US
Practice Address - Phone:515-451-3015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA05923104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
35021OtherBLUE CROSS BLUE SHIELD