Provider Demographics
NPI:1386656023
Name:BRACISZEWSKI, TERRY L (PHD,)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:L
Last Name:BRACISZEWSKI
Suffix:
Gender:M
Credentials:PHD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 W SIBLEY ST
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-2221
Mailing Address - Country:US
Mailing Address - Phone:734-320-2497
Mailing Address - Fax:810-231-0771
Practice Address - Street 1:7926 ANN ARBOR ST
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:MI
Practice Address - Zip Code:48130-1344
Practice Address - Country:US
Practice Address - Phone:734-320-2497
Practice Address - Fax:810-231-0771
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TB0200X, 103TH0100X, 103TR0400X, 261QR1300X
MI6301006431103TP2701X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680H146930OtherBCBSM
OH610093200OtherACS/OWCP
OH610093200OtherACS/OWCP
S01175Medicare UPIN