Provider Demographics
NPI:1710082243
Name:WILSON, TRACY LYNN (LLP, LPC, NCC)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:LLP, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-1432
Mailing Address - Country:US
Mailing Address - Phone:269-657-6025
Mailing Address - Fax:269-657-5198
Practice Address - Street 1:181 W MICHIGAN AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-1432
Practice Address - Country:US
Practice Address - Phone:269-657-6025
Practice Address - Fax:269-657-5198
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401006865101YM0800X
MI6301010633103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist