Provider Demographics
NPI:1790363992
Name:HARRIS-WILSON, TRACEY MONIQUE (MA, LLPC)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:MONIQUE
Last Name:HARRIS-WILSON
Suffix:
Gender:F
Credentials:MA, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24901 NORTHWESTERN HWY
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2203
Mailing Address - Country:US
Mailing Address - Phone:313-401-0990
Mailing Address - Fax:
Practice Address - Street 1:24901 NORTHWESTERN HWY
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2203
Practice Address - Country:US
Practice Address - Phone:313-401-0990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-30
Last Update Date:2021-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451015336101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional