Provider Demographics
NPI:1538673132
Name:SACKETT, TRACEY
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:SACKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19294 W WIECH RD
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-4033
Mailing Address - Country:US
Mailing Address - Phone:630-606-0740
Mailing Address - Fax:
Practice Address - Street 1:18160 W GAGES LAKE RD
Practice Address - Street 2:
Practice Address - City:GAGES LAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-1819
Practice Address - Country:US
Practice Address - Phone:847-548-8470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-20
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.007484235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist