MEDICARE: MRS. TRACY DIANE SOOS LCPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	22650	IL
2	101YP2500X	Professional Counselor	180007500	IL

General Provider Information

NPI Number	:	1285953034
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TRACY DIANE SOOS LCPC

Provider Business Mailing Address
First Line	:	1400 N SEMINARY AVE
Second Line	:	UNIT L
City	:	WOODSTOCK
State	:	IL
Zip	:	60098-2980
Country	:	US
Telephone Number	:	815-459-0499
Fax Number	:	815-788-0115

Provider Business Practice Location Address
First Line	:	1400 N SEMINARY AVE
Second Line	:	UNIT L
City	:	WOODSTOCK
State	:	IL
Zip	:	60098-2980
Country	:	US
Telephone Number	:	815-459-0499
Fax Number	:	815-788-0115

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2010
Last Update Date	:	05/19/2010

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