Provider Demographics
NPI:1952317919
Name:LEWIS-TODD, TRACY A (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:A
Last Name:LEWIS-TODD
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1228 EMERSON ST UNIT 503
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-3819
Mailing Address - Country:US
Mailing Address - Phone:847-769-7300
Mailing Address - Fax:877-885-1438
Practice Address - Street 1:1871 HICKS RD
Practice Address - Street 2:SUITE A
Practice Address - City:ROLLING MEADOWS
Practice Address - State:IL
Practice Address - Zip Code:60008-1215
Practice Address - Country:US
Practice Address - Phone:847-469-7300
Practice Address - Fax:877-885-1438
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071003414103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL21622467OtherBLUECROSS