Provider Demographics
NPI:1164606273
Name:GOMEZ, TRACY LYNN (PSYD LP)
Entity Type:Individual
Prefix:MISS
First Name:TRACY
Middle Name:LYNN
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:PSYD LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1783 COUNCIL AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-1206
Mailing Address - Country:US
Mailing Address - Phone:313-388-6466
Mailing Address - Fax:
Practice Address - Street 1:730 N MACOMB ST STE 200
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-2904
Practice Address - Country:US
Practice Address - Phone:734-240-1760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-26
Last Update Date:2020-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301018298103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical