Basic Information
| Provider Information | |||||||||
| NPI: | 1487129656 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TACEY | ||||||||
| FirstName: | HOLLY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | TLLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3040 DALTON DR | ||||||||
| Address2: | |||||||||
| City: | COMMERCE TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483903606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484621798 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1307 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481702217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344513440 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2018 | ||||||||
| LastUpdateDate: | 10/03/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6301017658 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.