Provider Demographics
NPI:1639365455
Name:HALL, TRACY TINA
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:TINA
Last Name:HALL
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:PO BOX 20208
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620-0208
Mailing Address - Country:US
Mailing Address - Phone:773-239-0047
Mailing Address - Fax:773-239-0047
Practice Address - Street 1:8302-10 SOUTH PAULINA
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60620
Practice Address - Country:US
Practice Address - Phone:773-239-0047
Practice Address - Fax:773-239-0047
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-16
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2216698174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist