Healthcare Provider Details

I. General information

NPI: 1902962178
Provider Name (Legal Business Name): MS. TRACI MELINDA FERTEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACI MELINDA FERTEL LCSW

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 05/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13300 DIVISION SUITE B7
PLAINFIELD IL
60585
US

IV. Provider business mailing address

1427 W SUMMERDALE AVE #3A
CHICAGO IL
60640-2127
US

V. Phone/Fax

Practice location:
  • Phone: 815-577-3666
  • Fax:
Mailing address:
  • Phone: 773-271-8081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149-001920
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number149-001920
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: