Healthcare Provider Details

I. General information

NPI: 1043068166
Provider Name (Legal Business Name): TRACY MCCONNELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2024
Last Update Date: 05/13/2024
Certification Date: 05/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2019 RAMBLING RD
KALAMAZOO MI
49008-1630
US

IV. Provider business mailing address

704 WESTBURY LN
KALAMAZOO MI
49006-2628
US

V. Phone/Fax

Practice location:
  • Phone: 269-345-0909
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: