Provider Demographics
NPI:1871646570
Name:BOUCK, TRACY M (LCPC)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:M
Last Name:BOUCK
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10733 S ARTESIAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-1219
Mailing Address - Country:US
Mailing Address - Phone:708-532-6951
Mailing Address - Fax:708-532-6952
Practice Address - Street 1:16744 OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-2894
Practice Address - Country:US
Practice Address - Phone:708-532-6951
Practice Address - Fax:708-532-6952
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9932251OtherBCBS ID NUMBER