Healthcare Provider Details

I. General information

NPI: 1104257690
Provider Name (Legal Business Name): TRACY ZAVALA LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2013
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 N STATE ST
STANTON MI
48888-9702
US

IV. Provider business mailing address

611 N STATE ST
STANTON MI
48888-9702
US

V. Phone/Fax

Practice location:
  • Phone: 989-831-7520
  • Fax:
Mailing address:
  • Phone: 989-831-7520
  • Fax: 989-831-7578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401014041
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: