Provider Demographics
NPI:1386816296
Name:TAKAKI, TRACY PUALANI (BC-DMT, LCPC)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:PUALANI
Last Name:TAKAKI
Suffix:
Gender:F
Credentials:BC-DMT, LCPC
Other - Prefix:MS
Other - First Name:TRACY
Other - Middle Name:LANI
Other - Last Name:TERSELIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BC-DMT, LCPC
Mailing Address - Street 1:1111 E ADDISON AVE
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-3774
Mailing Address - Country:US
Mailing Address - Phone:773-318-7331
Mailing Address - Fax:
Practice Address - Street 1:1111 E ADDISON AVE
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-3774
Practice Address - Country:US
Practice Address - Phone:773-318-7331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2023-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180006573101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional