Provider Demographics
NPI:1326657545
Name:BOATMON, TRACY RENEE (LLMSW)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:RENEE
Last Name:BOATMON
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35425 HAWTHORNE DR
Mailing Address - Street 2:
Mailing Address - City:ROMULUS
Mailing Address - State:MI
Mailing Address - Zip Code:48174-6330
Mailing Address - Country:US
Mailing Address - Phone:313-516-8717
Mailing Address - Fax:
Practice Address - Street 1:35425 HAWTHORNE DR
Practice Address - Street 2:
Practice Address - City:ROMULUS
Practice Address - State:MI
Practice Address - Zip Code:48174-6330
Practice Address - Country:US
Practice Address - Phone:313-516-8717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MI68011139861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical