MEDICARE: TRACY VADEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	247200000X	MI

General Provider Information

NPI Number	:	1578922530
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACY VADEN

Provider Business Mailing Address
First Line	:	1221 BOWERS ST UNIT 1154
Second Line	:
City	:	BIRMINGHAM
State	:	MI
Zip	:	48012-7046
Country	:	US
Telephone Number	:	313-617-6888
Fax Number	:

Provider Business Practice Location Address
First Line	:	1221 BOWERS ST UNIT 1154
Second Line	:
City	:	BIRMINGHAM
State	:	MI
Zip	:	48012-7046
Country	:	US
Telephone Number	:	313-617-6888
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/19/2016
Last Update Date	:	02/19/2016

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Directions to “ TRACY VADEN ” Practice Location

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