Provider Demographics
NPI:1538537410
Name:SUMMERVILLE, TRACEY (LCSW)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:SUMMERVILLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:
Other - Last Name:O'CONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:41 E 7TH ST
Mailing Address - Street 2:APT. 3
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-8011
Mailing Address - Country:US
Mailing Address - Phone:914-589-7904
Mailing Address - Fax:
Practice Address - Street 1:858 E 23RD ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-2820
Practice Address - Country:US
Practice Address - Phone:917-808-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-09
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
NY095441104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker