Provider Demographics
NPI:1871794891
Name:POWNEY, TRACIE MICHELLE (OTRL, LMHC, LMFTA)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:MICHELLE
Last Name:POWNEY
Suffix:
Gender:F
Credentials:OTRL, LMHC, LMFTA
Other - Prefix:
Other - First Name:TRACIE
Other - Middle Name:MICHELLE
Other - Last Name:CHURCHWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:4414 9TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-4015
Mailing Address - Country:US
Mailing Address - Phone:360-791-9336
Mailing Address - Fax:
Practice Address - Street 1:1107 W BAY DR NW
Practice Address - Street 2:SUITE 102
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-4668
Practice Address - Country:US
Practice Address - Phone:360-791-9336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00003125174400000X
WAOT 00003125225XM0800X, 225X00000X
WAMC 60556138101YM0800X, 101Y00000X
WAMG 60565629106H00000X
WALH60724718101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No174400000XOther Service ProvidersSpecialist
No225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental Health
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8341315Medicaid
WA8341315Medicaid