Basic Information
| Provider Information | |||||||||
| NPI: | 1003147968 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAGUE | ||||||||
| FirstName: | TRACI | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | MA, CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1218 W WRIGHTWOOD AVE | ||||||||
| Address2: | UNIT G | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606141224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174176000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4440 W 95TH ST | ||||||||
| Address2: | |||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604532600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086841989 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2010 | ||||||||
| LastUpdateDate: | 01/15/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 146.008233 | IL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.