Healthcare Provider Details

I. General information

NPI: 1831837061
Provider Name (Legal Business Name): TRACIE MARIE COLEMAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2022
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2013 IONE LN
AURORA IL
60503-7827
US

IV. Provider business mailing address

PO BOX 24449
NEW YORK NY
10087-0589
US

V. Phone/Fax

Practice location:
  • Phone: 630-391-6929
  • Fax: 217-803-8917
Mailing address:
  • Phone: 833-351-8255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6981602
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.031491
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberTPSW6717
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: