Provider Demographics
NPI:1184737272
Name:MATTHEWS, TRACY ANN (LMSW)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:ANN
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14960 E PARK ST
Mailing Address - Street 2:
Mailing Address - City:CAPAC
Mailing Address - State:MI
Mailing Address - Zip Code:48014-3177
Mailing Address - Country:US
Mailing Address - Phone:810-395-4343
Mailing Address - Fax:
Practice Address - Street 1:14960 E PARK ST
Practice Address - Street 2:
Practice Address - City:CAPAC
Practice Address - State:MI
Practice Address - Zip Code:48014-3177
Practice Address - Country:US
Practice Address - Phone:810-395-4343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010461711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM97240001Medicare ID - Type Unspecified