Provider Demographics
NPI:1609189422
Name:PAULL, TRACY
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:
Last Name:PAULL
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 1:1016 N PAULINA ST APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-8380
Mailing Address - Country:US
Mailing Address - Phone:847-404-2687
Mailing Address - Fax:
Practice Address - Street 1:345 E SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2654
Practice Address - Country:US
Practice Address - Phone:312-238-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-21
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242001449235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist