Basic Information
| Provider Information | |||||||||
| NPI: | 1760616874 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCOTT | ||||||||
| FirstName: | TRACEY | ||||||||
| MiddleName: | LYN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LBSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RIVARD | ||||||||
| OtherFirstName: | TRACEY | ||||||||
| OtherMiddleName: | LYN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1495 E VERNE RD | ||||||||
| Address2: | |||||||||
| City: | BURT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484179797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102573746 | ||||||||
| FaxNumber: | 8102573795 | ||||||||
| Practice Location | |||||||||
| Address1: | 420 W 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485032445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102573746 | ||||||||
| FaxNumber: | 8102573795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2009 | ||||||||
| LastUpdateDate: | 04/11/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6802068415 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.