Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 104100000X | Social Worker | MSW009682 | GA |
NPI | 1003404179 |
---|---|
Provider Name | Ms. Amy Lynn Tracy |
First Address | Saint Simons Island, GA 31522-1620 |
Second Address | Brunswick, GA 31525-2503 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/01/2021 |
Last Update Date | 05/01/2021 |