Provider Demographics
NPI:1003147968
Name:TAGUE, TRACI LYNN (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:LYNN
Last Name:TAGUE
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 W WRIGHTWOOD AVE
Mailing Address - Street 2:UNIT G
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1224
Mailing Address - Country:US
Mailing Address - Phone:217-417-6000
Mailing Address - Fax:
Practice Address - Street 1:4440 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2600
Practice Address - Country:US
Practice Address - Phone:708-684-1989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-15
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.008233235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist