Provider Demographics
NPI:1780769216
Name:TRACY, LYNETTE EFFIE (CDP, LICSW)
Entity type:Individual
Prefix:MS
First Name:LYNETTE
Middle Name:EFFIE
Last Name:TRACY
Suffix:
Gender:F
Credentials:CDP, LICSW
Other - Prefix:
Other - First Name:LYNETTE
Other - Middle Name:EFFIE
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1601 E 4TH PLAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-3753
Mailing Address - Country:US
Mailing Address - Phone:360-397-8246
Mailing Address - Fax:360-397-8450
Practice Address - Street 1:1601 E FOURTH PLAIN BLVD
Practice Address - Street 2:BLDG 17
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-3753
Practice Address - Country:US
Practice Address - Phone:360-397-8246
Practice Address - Fax:360-397-8450
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00005446101YA0400X
WALW 603639961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164936Medicaid
OR164936Medicaid