Provider Demographics
NPI:1518435635
Name:NIYO, TRACY LYNN (LCSW)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:NIYO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1258 CATALPA DR
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-2048
Mailing Address - Country:US
Mailing Address - Phone:248-224-3754
Mailing Address - Fax:
Practice Address - Street 1:801 W 11 MILE RD STE 230
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-5200
Practice Address - Country:US
Practice Address - Phone:248-308-5974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-06
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010716651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical