Provider Demographics
NPI:1609362581
Name:BARNES, TRACI M (LCDCIII161720)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:M
Last Name:BARNES
Suffix:
Gender:F
Credentials:LCDCIII161720
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4282 BENNINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44212-1752
Mailing Address - Country:US
Mailing Address - Phone:216-387-7277
Mailing Address - Fax:
Practice Address - Street 1:4770 BROADVIEW RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-4670
Practice Address - Country:US
Practice Address - Phone:216-741-2871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-03
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCIII.161720101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)