Provider Demographics
NPI:1548628142
Name:TRACY, EMMA DIANE (RSS)
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:DIANE
Last Name:TRACY
Suffix:
Gender:F
Credentials:RSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6909 E 99TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-5938
Mailing Address - Country:US
Mailing Address - Phone:918-850-4784
Mailing Address - Fax:
Practice Address - Street 1:6909 E 99TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5938
Practice Address - Country:US
Practice Address - Phone:918-850-4784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-10
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK129962171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator