Provider Demographics
NPI:1366800526
Name:CHARLES, TRACY (BS)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:CHARLES
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6037 NORTH 11TH STREET
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141
Mailing Address - Country:US
Mailing Address - Phone:215-588-5071
Mailing Address - Fax:
Practice Address - Street 1:6037 N 11TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3201
Practice Address - Country:US
Practice Address - Phone:215-588-5071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-03
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)