Healthcare Provider Details

I. General information

NPI: 1164544763
Provider Name (Legal Business Name): TRACIE DENISE COZART-BOSLEY LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 09/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19401 NORTHLINE RD
SOUTHGATE MI
48195-2277
US

IV. Provider business mailing address

10 PETERBORO ST
DETROIT MI
48201-2722
US

V. Phone/Fax

Practice location:
  • Phone: 734-785-7705
  • Fax: 734-287-8021
Mailing address:
  • Phone: 313-833-6272
  • Fax: 313-831-2604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801080981
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: