Healthcare Provider Details

I. General information

NPI: 1801876552
Provider Name (Legal Business Name): TRACY L COOPER MSW, LCSW, EI-IMH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2139 W BARRY AVE BASEMENT
CHICAGO IL
60618-8138
US

IV. Provider business mailing address

PO BOX 35309
ELMWOOD PARK IL
60707
US

V. Phone/Fax

Practice location:
  • Phone: 773-991-6187
  • Fax: 855-222-5962
Mailing address:
  • Phone: 773-991-6187
  • Fax: 855-222-5962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number149.011267
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number149.011267
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number149.011267
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number149.011267
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.011267
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: