Basic Information
| Provider Information | |||||||||
| NPI: | 1538466982 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLEDGE | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | YVONNE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LLBSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HARRIS | ||||||||
| OtherFirstName: | TRACY | ||||||||
| OtherMiddleName: | YVONNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 14198 LAMPHERE ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482232545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3134050270 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9315 TELEGRAPH RD | ||||||||
| Address2: | |||||||||
| City: | REDFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482391260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3134504500 | ||||||||
| FaxNumber: | 3134504512 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2011 | ||||||||
| LastUpdateDate: | 03/25/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6802089272 | MI | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 104100000X | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.