Provider Demographics
NPI:1205247335
Name:WICKLAND, TRACY (LMSW)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:WICKLAND
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 1:1 FORD PL
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3450
Mailing Address - Country:US
Mailing Address - Phone:313-874-6677
Mailing Address - Fax:
Practice Address - Street 1:3001 4TH ST
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-1358
Practice Address - Country:US
Practice Address - Phone:734-419-2200
Practice Address - Fax:734-272-4158
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010949211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical