Provider Demographics
NPI:1205091931
Name:MUKLEWICZ, TRACY L (LCPC)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:MUKLEWICZ
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 1:27 W 140 ROOSEVELT ROAD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1641
Mailing Address - Country:US
Mailing Address - Phone:847-752-9969
Mailing Address - Fax:847-628-0791
Practice Address - Street 1:27W140 ROOSEVELT ROAD
Practice Address - Street 2:SUITE 205
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1641
Practice Address - Country:US
Practice Address - Phone:847-752-9969
Practice Address - Fax:847-628-0791
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-22
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180006950101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
11876841OtherCAQH