Provider Demographics
NPI:1831690296
Name:DAVIS, TRACY L (MS)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MISS
Other - First Name:TRACY
Other - Middle Name:L
Other - Last Name:OGLESBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1847
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-8140
Mailing Address - Country:US
Mailing Address - Phone:360-423-0203
Mailing Address - Fax:360-577-0269
Practice Address - Street 1:305 PACIFIC AVE S STE 102
Practice Address - Street 2:
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-1638
Practice Address - Country:US
Practice Address - Phone:360-423-0203
Practice Address - Fax:360-423-5086
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60797965101Y00000X
WA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2097679Medicaid