Provider Demographics
NPI:1023045580
Name:STAMM, TRACI
Entity Type:Individual
Prefix:MS
First Name:TRACI
Middle Name:
Last Name:STAMM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7124 WINDSOR LAKE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111
Mailing Address - Country:US
Mailing Address - Phone:815-986-0668
Mailing Address - Fax:815-987-2592
Practice Address - Street 1:7124 WINDSOR LAKE PKWY
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-3800
Practice Address - Country:US
Practice Address - Phone:815-986-0668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional