Provider Demographics
NPI:1821248865
Name:EDWARDS, TRACIE R
Entity Type:Individual
Prefix:MRS
First Name:TRACIE
Middle Name:R
Last Name:EDWARDS
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 1:1110 ELDON BAKER DR
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-1923
Mailing Address - Country:US
Mailing Address - Phone:810-213-1803
Mailing Address - Fax:810-744-1306
Practice Address - Street 1:1110 ELDON BAKER DR
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-1923
Practice Address - Country:US
Practice Address - Phone:810-213-1803
Practice Address - Fax:810-744-1306
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-26
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011486101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional