Provider Demographics
NPI:1174967574
Name:WILLIAMS DAVIS, TRACY
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:WILLIAMS DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1503 W 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-3412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1503 W 7TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-3412
Practice Address - Country:US
Practice Address - Phone:509-747-7147
Practice Address - Fax:509-747-3828
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACL 603141841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA00000OtherONE HEALTH PORT