Provider Demographics
NPI:1508401209
Name:CUNNINGHAM, TRACY LYNN (LCSW)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:684 W BOUGHTON RD STE 106
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-1781
Mailing Address - Country:US
Mailing Address - Phone:630-410-9578
Mailing Address - Fax:630-296-0749
Practice Address - Street 1:684 W BOUGHTON RD STE 106
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-1781
Practice Address - Country:US
Practice Address - Phone:630-410-9578
Practice Address - Fax:630-296-0749
Is Sole Proprietor?:No
Enumeration Date:2019-11-17
Last Update Date:2019-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490159671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
350601850OtherCLINICAL SOCIAL WORK