Provider Demographics
NPI:1902962178
Name:FERTEL, TRACI MELINDA
Entity Type:Individual
Prefix:MS
First Name:TRACI
Middle Name:MELINDA
Last Name:FERTEL
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:TRACI
Other - Middle Name:MELINDA
Other - Last Name:FERTEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1427 W SUMMERDALE AVE
Mailing Address - Street 2:#3A
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2127
Mailing Address - Country:US
Mailing Address - Phone:773-271-8081
Mailing Address - Fax:
Practice Address - Street 1:13300 DIVISION
Practice Address - Street 2:SUITE B7
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585
Practice Address - Country:US
Practice Address - Phone:815-577-3666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0019201041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool