Provider Demographics
NPI:1295854263
Name:KROEGER, TRACY LYNN (PHD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:LYNN
Last Name:KROEGER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7086 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49428-9352
Mailing Address - Country:US
Mailing Address - Phone:616-667-9551
Mailing Address - Fax:616-667-9552
Practice Address - Street 1:7086 8TH AVE
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-9352
Practice Address - Country:US
Practice Address - Phone:616-667-9551
Practice Address - Fax:616-667-9552
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011127103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical