Provider Demographics
NPI:1700181211
Name:TRACEY TOROSIAN, PH.D., PLLC
Entity type:Organization
Organization Name:TRACEY TOROSIAN, PH.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:TOROSIAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:586-774-7344
Mailing Address - Street 1:20816 E 11 MILE RD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-1565
Mailing Address - Country:US
Mailing Address - Phone:586-774-7344
Mailing Address - Fax:586-774-7345
Practice Address - Street 1:20816 E 11 MILE RD
Practice Address - Street 2:SUITE 112
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-1565
Practice Address - Country:US
Practice Address - Phone:586-774-7344
Practice Address - Fax:586-774-7345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-13
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009014261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1962531335OtherNPI TYPE 1
MI680E046090OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI680E046090OtherBLUE CROSS BLUE SHIELD OF MICHIGAN