Provider Demographics
NPI:1154889459
Name:TRAC AUTISM CENTER INC.
Entity type:Organization
Organization Name:TRAC AUTISM CENTER INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-513-0782
Mailing Address - Street 1:3290 W BIG BEAVER RD STE 510
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-2917
Mailing Address - Country:US
Mailing Address - Phone:586-404-9400
Mailing Address - Fax:
Practice Address - Street 1:10751 S SAGINAW ST STE E
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-8169
Practice Address - Country:US
Practice Address - Phone:586-404-9400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-05
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No252Y00000XAgenciesEarly Intervention Provider Agency
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QR1100XAmbulatory Health Care FacilitiesClinic/CenterResearch
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1124405873Medicaid