Provider Demographics
NPI:1750304291
Name:WILSON, TRACI (MA LLP)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA LLP
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:
Other - Last Name:HAWKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA LLP
Mailing Address - Street 1:24 FRANK LLOYD
Mailing Address - Street 2:STE J2000
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105
Mailing Address - Country:US
Mailing Address - Phone:734-747-6766
Mailing Address - Fax:734-222-3100
Practice Address - Street 1:350 NORTH MAIN STREET
Practice Address - Street 2:SUITE 150
Practice Address - City:CHELSEA
Practice Address - State:MI
Practice Address - Zip Code:48118
Practice Address - Country:US
Practice Address - Phone:734-593-5251
Practice Address - Fax:734-593-5255
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361003300103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI204862865OtherTAX ID