Healthcare Provider Details

I. General information

NPI: 1750304291
Provider Name (Legal Business Name): TRACI WILSON MA LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TRACI HAWKINS MA LLP

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/26/2024
Certification Date: 01/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 NORTH MAIN STREET SUITE 150
CHELSEA MI
48118
US

IV. Provider business mailing address

24 FRANK LLOYD STE J2000
ANN ARBOR MI
48105
US

V. Phone/Fax

Practice location:
  • Phone: 734-593-5251
  • Fax: 734-593-5255
Mailing address:
  • Phone: 734-747-6766
  • Fax: 734-222-3100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6361003300
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: