Provider Demographics
NPI:1154996254
Name:COLEMAN, TRACY LYNN (PEER RECOVERY COACH)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:PEER RECOVERY COACH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6292 RESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:MI
Mailing Address - Zip Code:48451-8708
Mailing Address - Country:US
Mailing Address - Phone:810-845-0875
Mailing Address - Fax:
Practice Address - Street 1:DETROIT RECOVERY PROJECT
Practice Address - Street 2:1145 WEST GRAND BLVD.
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208
Practice Address - Country:US
Practice Address - Phone:313-365-3100
Practice Address - Fax:313-365-3101
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-21
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YM0800X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty