Provider Demographics
NPI:1629281803
Name:BISHOP, TRACI LYNN (MSW)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:LYNN
Last Name:BISHOP
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 W MULBERRY ST
Mailing Address - Street 2:P.O. BOX 322
Mailing Address - City:WATSEKA
Mailing Address - State:IL
Mailing Address - Zip Code:60970-1568
Mailing Address - Country:US
Mailing Address - Phone:815-432-5241
Mailing Address - Fax:815-432-4537
Practice Address - Street 1:323 W MULBERRY ST
Practice Address - Street 2:
Practice Address - City:WATSEKA
Practice Address - State:IL
Practice Address - Zip Code:60970-1568
Practice Address - Country:US
Practice Address - Phone:815-432-5241
Practice Address - Fax:815-432-4537
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490139181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical