Provider Demographics
NPI:1952713612
Name:TRACY, MARLA (LCSW)
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:
Last Name:TRACY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:939 FAIRLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-3045
Mailing Address - Country:US
Mailing Address - Phone:847-508-6700
Mailing Address - Fax:
Practice Address - Street 1:4212 OLD GRAND AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-2708
Practice Address - Country:US
Practice Address - Phone:847-336-5621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-28
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0021201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical