Healthcare Provider Details

I. General information

NPI: 1164091500
Provider Name (Legal Business Name): TRACEY BELL-HODGMAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2021
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 E LAKE ST
CHICAGO IL
60601-5959
US

IV. Provider business mailing address

1208 W MONTROSE AVE
CHICAGO IL
60613-1633
US

V. Phone/Fax

Practice location:
  • Phone: 312-726-4011
  • Fax:
Mailing address:
  • Phone: 517-214-7348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149023265
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: