Basic Information
Provider Information | |||||||||
NPI: | 1447387550 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DUNTON | ||||||||
FirstName: | TRACY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 45642 PENTWATER DR | ||||||||
Address2: |   | ||||||||
City: | MACOMB | ||||||||
State: | MI | ||||||||
PostalCode: | 480444237 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5863433458 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 46360 GRATIOT AVE | ||||||||
Address2: |   | ||||||||
City: | CHESTERFIELD | ||||||||
State: | MI | ||||||||
PostalCode: | 480512800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5869480224 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/27/2007 | ||||||||
LastUpdateDate: | 01/25/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/25/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 6401005321 | MI | Y |   | Behavioral Health & Social Service Providers | Counselor |   |
No ID Information.