Provider Demographics
NPI:1356084040
Name:BOYD, TRACI DEANN
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:DEANN
Last Name:BOYD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25607 GREENFIELD RD APT 104
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2119
Mailing Address - Country:US
Mailing Address - Phone:313-434-9601
Mailing Address - Fax:
Practice Address - Street 1:25607 GREENFIELD RD APT 104
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2119
Practice Address - Country:US
Practice Address - Phone:313-434-9601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator