=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700162583
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACY BISTERFELDT PSY.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2011
-----------------------------------------------------
Last Update Date | 10/25/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 53 W. JACKSON BLVD. UNIT 635
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-379-2959
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 934 N. GROVE AVE.
-----------------------------------------------------
City | OAK PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-379-2959
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 071.008187
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------