Basic Information
| Provider Information | |||||||||
| NPI: | 1144503947 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAWKINS | ||||||||
| FirstName: | TRACI | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | SWT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAWKINS | ||||||||
| OtherFirstName: | TRACY | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | DEPT 781625 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482781625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143558004 | ||||||||
| FaxNumber: | 6143552220 | ||||||||
| Practice Location | |||||||||
| Address1: | 6435 E. BROAD STREET | ||||||||
| Address2: | SUITE A | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143558160 | ||||||||
| FaxNumber: | 6143558180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2011 | ||||||||
| LastUpdateDate: | 10/07/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S.1201092 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 2846675 | 05 | OH | MEDICAID |