Healthcare Provider Details

I. General information

NPI: 1699000125
Provider Name (Legal Business Name): TRACY FEHRENBACH PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2009
Last Update Date: 10/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

446 E ONTARIO ST STE 7-100
CHICAGO IL
60611-4418
US

IV. Provider business mailing address

3330 W 177TH ST SUITE 1-F
HAZEL CREST IL
60429-2184
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-5060
  • Fax: 312-695-5010
Mailing address:
  • Phone: 773-573-5847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071006910
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: