Provider Demographics
NPI:1871291112
Name:TRACEY, AUSTIN (CGC)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:TRACEY
Suffix:
Gender:M
Credentials:CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3950 BEAUBIEN BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2120
Mailing Address - Country:US
Mailing Address - Phone:313-832-9264
Mailing Address - Fax:313-993-8685
Practice Address - Street 1:3950 BEAUBIEN BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2120
Practice Address - Country:US
Practice Address - Phone:313-832-9264
Practice Address - Fax:313-993-8685
Is Sole Proprietor?:No
Enumeration Date:2023-02-16
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7201000362170300000X
CT351170300000X
FL348170300000X
MTGEN-GEN-LIC-000467170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS