Provider Demographics
NPI:1538466982
Name:MILLEDGE, TRACY YVONNE (LLBSW)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:YVONNE
Last Name:MILLEDGE
Suffix:
Gender:F
Credentials:LLBSW
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:YVONNE
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:14198 LAMPHERE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-2545
Mailing Address - Country:US
Mailing Address - Phone:313-405-0270
Mailing Address - Fax:
Practice Address - Street 1:9315 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239-1260
Practice Address - Country:US
Practice Address - Phone:313-450-4500
Practice Address - Fax:313-450-4512
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-22
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802089272101YM0800X
MI104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health