Provider Demographics
NPI:1417163296
Name:BLACKWELL, TRACY J (LLPC)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:J
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2452
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-7452
Mailing Address - Country:US
Mailing Address - Phone:734-819-1747
Mailing Address - Fax:
Practice Address - Street 1:2262 N MONROE ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-4254
Practice Address - Country:US
Practice Address - Phone:734-430-9394
Practice Address - Fax:734-687-6198
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010214101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor