Provider Demographics
NPI:1316116767
Name:TREDENNICK, TRACY (LCSW)
Entity type:Individual
Prefix:MISS
First Name:TRACY
Middle Name:
Last Name:TREDENNICK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1322 EISENHOWER BLVD.
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15904-3307
Mailing Address - Country:US
Mailing Address - Phone:814-266-8840
Mailing Address - Fax:814-266-2176
Practice Address - Street 1:865 EISENHOWER BLVD.
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15904-3327
Practice Address - Country:US
Practice Address - Phone:814-266-8840
Practice Address - Fax:814-266-2176
Is Sole Proprietor?:No
Enumeration Date:2008-02-29
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0158021041C0700X
PACW105802208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007708200003Medicaid
PA1025856980001Medicaid