Basic Information
| Provider Information | |||||||||
| NPI: | 1164606273 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOMEZ | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | PSYD LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1783 COUNCIL AVE | ||||||||
| Address2: | |||||||||
| City: | LINCOLN PARK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481461206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133886466 | ||||||||
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| Practice Location | |||||||||
| Address1: | 730 N MACOMB ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481622904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342401760 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2007 | ||||||||
| LastUpdateDate: | 03/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6301018298 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.