Provider Demographics
NPI:1801876552
Name:COOPER, TRACY L (MSW, LCSW, EI-IMH)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:COOPER
Suffix:
Gender:F
Credentials:MSW, LCSW, EI-IMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 35309
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60707
Mailing Address - Country:US
Mailing Address - Phone:773-991-6187
Mailing Address - Fax:855-222-5962
Practice Address - Street 1:2139 W BARRY AVE
Practice Address - Street 2:BASEMENT
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-8138
Practice Address - Country:US
Practice Address - Phone:773-991-6187
Practice Address - Fax:855-222-5962
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.011267103TM1800X, 2080P0006X, 103TC2200X, 251S00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No251S00000XAgenciesCommunity/Behavioral Health