Provider Demographics
NPI:1750304291
Name:WILSON, TRACI BRENISER (MA LLP)
Entity Type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:BRENISER
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA LLP
Other - Prefix:MS
Other - First Name:TRACI
Other - Middle Name:BRENISER
Other - Last Name:HAWKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA LLP
Mailing Address - Street 1:124 NICOLE DR
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:MI
Mailing Address - Zip Code:49230
Mailing Address - Country:US
Mailing Address - Phone:517-414-0065
Mailing Address - Fax:
Practice Address - Street 1:225 SOUTH MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:BROOKLYN
Practice Address - State:MI
Practice Address - Zip Code:49230
Practice Address - Country:US
Practice Address - Phone:517-414-0065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITH008036103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI204862865OtherTAX ID