Provider Demographics
NPI:1871019919
Name:BLAD, TRACY (MA,LMFT)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:BLAD
Suffix:
Gender:F
Credentials:MA,LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28301 HUMBER ST NE
Mailing Address - Street 2:
Mailing Address - City:NORTH BRANCH
Mailing Address - State:MN
Mailing Address - Zip Code:55056-6353
Mailing Address - Country:US
Mailing Address - Phone:651-808-0445
Mailing Address - Fax:
Practice Address - Street 1:2201 NW CORPORATE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-7337
Practice Address - Country:US
Practice Address - Phone:561-617-8751
Practice Address - Fax:561-423-0711
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-21
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2917101YM0800X
FLMT4965106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health