Provider Demographics
NPI:1609686013
Name:HARBUCK, TRACY LEE
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LEE
Last Name:HARBUCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 E ST
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-8406
Mailing Address - Country:US
Mailing Address - Phone:575-291-5613
Mailing Address - Fax:
Practice Address - Street 1:801 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801-4254
Practice Address - Country:US
Practice Address - Phone:575-622-6299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty