Provider Demographics
NPI:1225120900
Name:NITTA TAKEDA, TRACY KIMIE (MA , LCPC)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:KIMIE
Last Name:NITTA TAKEDA
Suffix:
Gender:F
Credentials:MA , LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 BAY SCOTT CIR STE 109
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-1130
Mailing Address - Country:US
Mailing Address - Phone:630-357-2456
Mailing Address - Fax:630-357-2482
Practice Address - Street 1:330 DIVISION DR STE J
Practice Address - Street 2:
Practice Address - City:SUGAR GROVE
Practice Address - State:IL
Practice Address - Zip Code:60554-9800
Practice Address - Country:US
Practice Address - Phone:630-884-1708
Practice Address - Fax:630-277-8362
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-002939101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional