Healthcare Provider Details

I. General information

NPI: 1225271232
Provider Name (Legal Business Name): TRACY BAUM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2009
Last Update Date: 04/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 S MARION ST
OAK PARK IL
60302-2809
US

IV. Provider business mailing address

680 N LAKE SHORE DR # 802
CHICAGO IL
60611-4546
US

V. Phone/Fax

Practice location:
  • Phone: 708-383-7500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180006770
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: