Basic Information
| Provider Information | |||||||||
| NPI: | 1760713739 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COFFEY | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 664 | ||||||||
| Address2: | |||||||||
| City: | NORTH AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605420140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309079104 | ||||||||
| FaxNumber: | 8473818042 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 W STATE ST | ||||||||
| Address2: | SUITE 107D | ||||||||
| City: | GENEVA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601342080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302676794 | ||||||||
| FaxNumber: | 6309079104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2010 | ||||||||
| LastUpdateDate: | 10/30/2015 | ||||||||
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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 | 1041C0700X | 149014084 | IL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 149.014084 | IL | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.