Provider Demographics
NPI:1568657500
Name:FAY, TRACY LIN (MASTERS LTD PSYCHOLO)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:LIN
Last Name:FAY
Suffix:
Gender:F
Credentials:MASTERS LTD PSYCHOLO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 219
Mailing Address - Street 2:801 HAZEN STREET
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-0249
Mailing Address - Country:US
Mailing Address - Phone:269-657-5574
Mailing Address - Fax:269-657-3474
Practice Address - Street 1:57418 CR 681
Practice Address - Street 2:SUITE C
Practice Address - City:HARTFORD
Practice Address - State:MI
Practice Address - Zip Code:49057
Practice Address - Country:US
Practice Address - Phone:269-621-6251
Practice Address - Fax:269-621-6044
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010602103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist