Provider Demographics
NPI:1851570436
Name:BLAKE, TRACY R (RD)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:R
Last Name:BLAKE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15300 WEST AVE STE 221
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-4508
Mailing Address - Country:US
Mailing Address - Phone:708-590-5300
Mailing Address - Fax:708-590-5310
Practice Address - Street 1:15300 WEST AVE STE 221
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-4508
Practice Address - Country:US
Practice Address - Phone:708-590-5300
Practice Address - Fax:708-590-5310
Is Sole Proprietor?:No
Enumeration Date:2007-10-30
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.004441133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid