Provider Demographics
NPI:1689922585
Name:EAGLE, TRACY LEE (MS)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:LEE
Last Name:EAGLE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MRS
Other - First Name:TRACY
Other - Middle Name:LEE
Other - Last Name:GALLATIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS, FAODP
Mailing Address - Street 1:96 E GORDONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-8384
Mailing Address - Country:US
Mailing Address - Phone:989-790-3366
Mailing Address - Fax:989-790-5027
Practice Address - Street 1:4151 SHRESTHA DRIVE
Practice Address - Street 2:STE D
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-2190
Practice Address - Country:US
Practice Address - Phone:989-220-3060
Practice Address - Fax:989-790-5027
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION80300OtherMEDICARE