Provider Demographics
NPI:1104525997
Name:SAMPSON, TRACI LINN (MA, LLC, NCC)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:LINN
Last Name:SAMPSON
Suffix:
Gender:F
Credentials:MA, LLC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9001 MILLER RD STE 3
Mailing Address - Street 2:
Mailing Address - City:SWARTZ CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:48473-1115
Mailing Address - Country:US
Mailing Address - Phone:810-919-1690
Mailing Address - Fax:
Practice Address - Street 1:9001 MILLER RD STE 3
Practice Address - Street 2:
Practice Address - City:SWARTZ CREEK
Practice Address - State:MI
Practice Address - Zip Code:48473-1115
Practice Address - Country:US
Practice Address - Phone:810-919-1690
Practice Address - Fax:810-635-4626
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-01
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451022551101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health