Provider Demographics
NPI:1699000125
Name:FEHRENBACH, TRACY (PHD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:FEHRENBACH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3330 W 177TH ST
Mailing Address - Street 2:SUITE 1-F
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429-2184
Mailing Address - Country:US
Mailing Address - Phone:773-573-5847
Mailing Address - Fax:
Practice Address - Street 1:446 E ONTARIO ST STE 7-100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4418
Practice Address - Country:US
Practice Address - Phone:312-695-5060
Practice Address - Fax:312-695-5010
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-16
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006910103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical