Provider Demographics
NPI:1629319058
Name:MCCULLY, TRACIE LYNN (MSW, LMSW)
Entity Type:Individual
Prefix:MRS
First Name:TRACIE
Middle Name:LYNN
Last Name:MCCULLY
Suffix:
Gender:F
Credentials:MSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8028 BROOKE PARK DR
Mailing Address - Street 2:APT 210
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-5100
Mailing Address - Country:US
Mailing Address - Phone:734-626-4171
Mailing Address - Fax:
Practice Address - Street 1:13101 ALLEN RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2216
Practice Address - Country:US
Practice Address - Phone:734-785-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801088381104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker