Provider Demographics
NPI:1376728931
Name:BALOUN, TRACY J (DT)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:J
Last Name:BALOUN
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 LONGTREE DRIVE
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:IL
Mailing Address - Zip Code:60090
Mailing Address - Country:US
Mailing Address - Phone:847-947-2102
Mailing Address - Fax:
Practice Address - Street 1:509 LONGTREE DRIVE
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:IL
Practice Address - Zip Code:60090
Practice Address - Country:US
Practice Address - Phone:847-947-2102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-02
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILJB64100107P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist