Basic Information
| Provider Information | |||||||||
| NPI: | 1881137891 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FROSTICK | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | |||||||||
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| Credential: | MSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HADERER | ||||||||
| OtherFirstName: | TRACY | ||||||||
| OtherMiddleName: | LEE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 201 MONROE AVE NW | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006004096 | ||||||||
| FaxNumber: | 8006068839 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 MONROE AVE NW | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006004096 | ||||||||
| FaxNumber: | 8006068839 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2016 | ||||||||
| LastUpdateDate: | 11/22/2016 | ||||||||
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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 | 1041C0700X | 6801096614 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.