Basic Information
| Provider Information | |||||||||
| NPI: | 1295854263 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KROEGER | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7086 8TH AVE | ||||||||
| Address2: | |||||||||
| City: | JENISON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494289352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166679551 | ||||||||
| FaxNumber: | 6166679552 | ||||||||
| Practice Location | |||||||||
| Address1: | 7086 8TH AVE | ||||||||
| Address2: | |||||||||
| City: | JENISON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494289352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166679551 | ||||||||
| FaxNumber: | 6166679552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6301011127 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.