Provider Demographics
NPI:1700162583
Name:BISTERFELDT, TRACY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:
Last Name:BISTERFELDT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:TRACY
Other - Middle Name:M
Other - Last Name:SCHAFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:934 N. GROVE AVE.
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302
Mailing Address - Country:US
Mailing Address - Phone:414-379-2959
Mailing Address - Fax:
Practice Address - Street 1:53 W. JACKSON BLVD.
Practice Address - Street 2:UNIT 635
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60604
Practice Address - Country:US
Practice Address - Phone:414-379-2959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-25
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.008187103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical