Provider Demographics
NPI:1992911580
Name:STULBERG, TRACEY LYNN (PHD)
Entity type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:LYNN
Last Name:STULBERG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 S OLD WOODWARD AVE
Mailing Address - Street 2:108
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6723
Mailing Address - Country:US
Mailing Address - Phone:248-258-9189
Mailing Address - Fax:248-258-2897
Practice Address - Street 1:1000 S OLD WOODWARD AVE
Practice Address - Street 2:108
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6723
Practice Address - Country:US
Practice Address - Phone:248-258-9189
Practice Address - Fax:248-258-2897
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4101005410106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist