Provider Demographics
NPI:1811556202
Name:FALLETICH, TRACEY LYNN
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:LYNN
Last Name:FALLETICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36118 CANYON DR
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48186-4162
Mailing Address - Country:US
Mailing Address - Phone:734-721-6055
Mailing Address - Fax:
Practice Address - Street 1:35425 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-9800
Practice Address - Country:US
Practice Address - Phone:734-722-5986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802089266171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator