Provider Demographics
NPI:1720493398
Name:THEARD, TRACY (MA)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:THEARD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1859 BLACK RD
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-3535
Mailing Address - Country:US
Mailing Address - Phone:815-730-8900
Mailing Address - Fax:815-733-6030
Practice Address - Street 1:1859 BLACK RD
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-3535
Practice Address - Country:US
Practice Address - Phone:815-730-8900
Practice Address - Fax:815-733-6030
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-23
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.009965101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health