Provider Demographics
NPI:1194932962
Name:MARTIN, TRACEY LEEANN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:LEEANN
Last Name:MARTIN
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 1:17506 OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60487-6128
Mailing Address - Country:US
Mailing Address - Phone:815-207-1943
Mailing Address - Fax:
Practice Address - Street 1:9200 W 191ST ST
Practice Address - Street 2:UNIT 6 SUITE 1C
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448
Practice Address - Country:US
Practice Address - Phone:708-690-8820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490121661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical