=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104615376
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACEY MAKOWSKI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2025
-----------------------------------------------------
Last Update Date | 05/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1122 WALNUT ST
-----------------------------------------------------
City | YPSILANTI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48198-3937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-252-5215
-----------------------------------------------------
Fax | 734-822-0237
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1122 WALNUT ST
-----------------------------------------------------
City | YPSILANTI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48198-3937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-252-5215
-----------------------------------------------------
Fax | 734-822-0237
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------