Provider Demographics
NPI:1417589805
Name:HARRIS, TRACY LYNNE
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNNE
Last Name:HARRIS
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 1:1182 VILLA PARK DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-1314
Mailing Address - Country:US
Mailing Address - Phone:248-219-8700
Mailing Address - Fax:
Practice Address - Street 1:30101 HOOVER RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-6572
Practice Address - Country:US
Practice Address - Phone:586-558-6868
Practice Address - Fax:586-558-6893
Is Sole Proprietor?:No
Enumeration Date:2020-02-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401018137101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health