=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972791101
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY BUILDING BLOCKS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2007
-----------------------------------------------------
Last Update Date | 11/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10337 S MAPLEWOOD AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60655-1022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-771-2186
-----------------------------------------------------
Fax | 866-897-4573
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10337 S MAPLEWOOD AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60655-1022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-771-2186
-----------------------------------------------------
Fax | 866-897-4573
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TRACY BOUCK
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 773-429-9454
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180004699
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------