Provider Demographics
NPI:1871014183
Name:THOMAS, TRACY L (RN, LCDCIII)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:THOMAS
Suffix:
Gender:F
Credentials:RN, LCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 EASTLAND RD
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-1217
Mailing Address - Country:US
Mailing Address - Phone:440-260-8327
Mailing Address - Fax:440-234-8319
Practice Address - Street 1:111 S BROAD ST STE 209
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130
Practice Address - Country:US
Practice Address - Phone:614-230-6049
Practice Address - Fax:614-928-9094
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-28
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCIII.161575101YA0400X
OHRN.305429163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHRN.305429OtherRN LICENSE