Provider Demographics
NPI:1861097909
Name:WILSON, TRACY BRUCE
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:BRUCE
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6280 DEERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-4559
Mailing Address - Country:US
Mailing Address - Phone:334-399-1036
Mailing Address - Fax:
Practice Address - Street 1:2400 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:TUSKEGEE
Practice Address - State:AL
Practice Address - Zip Code:36083-5001
Practice Address - Country:US
Practice Address - Phone:334-727-0550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4885G104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker