Healthcare Provider Details

I. General information

NPI: 1013233444
Provider Name (Legal Business Name): TRACY L CUPPER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2010
Last Update Date: 09/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 HUNTINGTON DR
CALUMET CITY IL
60409-5440
US

IV. Provider business mailing address

1551 HUNTINGTON DR
CALUMET CITY IL
60409-5440
US

V. Phone/Fax

Practice location:
  • Phone: 708-915-4739
  • Fax:
Mailing address:
  • Phone: 708-915-4739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149014089
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: