Healthcare Provider Details

I. General information

NPI: 1154996254
Provider Name (Legal Business Name): TRACY LYNN COLEMAN PEER RECOVERY COACH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2021
Last Update Date: 05/21/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DETROIT RECOVERY PROJECT 1145 WEST GRAND BLVD.
DETROIT MI
48208
US

IV. Provider business mailing address

6292 RESTWOOD DR
LINDEN MI
48451-8708
US

V. Phone/Fax

Practice location:
  • Phone: 313-365-3100
  • Fax: 313-365-3101
Mailing address:
  • Phone: 810-845-0875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: