Healthcare Provider Details

I. General information

NPI: 1164606273
Provider Name (Legal Business Name): TRACY LYNN GOMEZ PSYD LP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2007
Last Update Date: 03/28/2020
Certification Date: 03/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 N MACOMB ST STE 200
MONROE MI
48162-2904
US

IV. Provider business mailing address

1783 COUNCIL AVE
LINCOLN PARK MI
48146-1206
US

V. Phone/Fax

Practice location:
  • Phone: 734-240-1760
  • Fax:
Mailing address:
  • Phone: 313-388-6466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301018298
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: