Provider Demographics
NPI:1508620212
Name:LUMETTA, TRACI MARIE
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:MARIE
Last Name:LUMETTA
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 1:50194 SCHOENHERR RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-3136
Mailing Address - Country:US
Mailing Address - Phone:586-991-6596
Mailing Address - Fax:
Practice Address - Street 1:50194 SCHOENHERR RD
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-3136
Practice Address - Country:US
Practice Address - Phone:586-991-6596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101200000X
101200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101200000XBehavioral Health & Social Service ProvidersDrama Therapist