Provider Demographics
NPI:1053462952
Name:TYLAR, TRACI JO (LPC)
Entity Type:Individual
Prefix:MS
First Name:TRACI
Middle Name:JO
Last Name:TYLAR
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9665
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61612
Mailing Address - Country:US
Mailing Address - Phone:309-573-4834
Mailing Address - Fax:312-254-1423
Practice Address - Street 1:5016 N. UNIVERSITY ST.
Practice Address - Street 2:SUITE 109
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614
Practice Address - Country:US
Practice Address - Phone:309-573-4834
Practice Address - Fax:312-254-1423
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178004736101YP2500X
IL178994736101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional