Provider Demographics
NPI:1780723056
Name:WILLIAMSON, TRACEY L (DC)
Entity type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:L
Last Name:WILLIAMSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20744 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:ROMULUS
Mailing Address - State:MI
Mailing Address - Zip Code:48174-9319
Mailing Address - Country:US
Mailing Address - Phone:734-479-9355
Mailing Address - Fax:734-479-0378
Practice Address - Street 1:20744 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:ROMULUS
Practice Address - State:MI
Practice Address - Zip Code:48174-9319
Practice Address - Country:US
Practice Address - Phone:734-479-9355
Practice Address - Fax:734-479-0378
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITW005235111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H25167Medicare ID - Type Unspecified
MIP98262Medicare UPIN