Provider Demographics
NPI:1861700031
Name:SOUZA, TRACY L (LCSW)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:SOUZA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:L
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 1763
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-1763
Mailing Address - Country:US
Mailing Address - Phone:207-299-3463
Mailing Address - Fax:186-628-3526
Practice Address - Street 1:263 STATE ST STE 9
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5461
Practice Address - Country:US
Practice Address - Phone:207-299-3463
Practice Address - Fax:866-283-5267
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-21
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC135971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical