Provider Demographics
NPI:1487129656
Name:TACEY, HOLLY J (TLLP)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:J
Last Name:TACEY
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3040 DALTON DR
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48390-3606
Mailing Address - Country:US
Mailing Address - Phone:248-462-1798
Mailing Address - Fax:
Practice Address - Street 1:1307 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-2217
Practice Address - Country:US
Practice Address - Phone:734-451-3440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301017658103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical