Healthcare Provider Details

I. General information

NPI: 1205331741
Provider Name (Legal Business Name): TRACEY A RENO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 03/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 W BIG BEAVER RD STE 1450
TROY MI
48084-4762
US

IV. Provider business mailing address

1125 E GUNN RD
ROCHESTER MI
48306-1913
US

V. Phone/Fax

Practice location:
  • Phone: 248-244-8644
  • Fax:
Mailing address:
  • Phone: 586-453-1065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401013692
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: