Provider Demographics
NPI:1962913103
Name:BARRY, TRACIE VITKAUSKAS (MS)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:VITKAUSKAS
Last Name:BARRY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14801 TURNER AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:IL
Mailing Address - Zip Code:60445-3628
Mailing Address - Country:US
Mailing Address - Phone:708-371-6340
Mailing Address - Fax:
Practice Address - Street 1:14801 TURNER AVE
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:IL
Practice Address - Zip Code:60445-3628
Practice Address - Country:US
Practice Address - Phone:708-371-6340
Practice Address - Fax:708-371-6340
Is Sole Proprietor?:No
Enumeration Date:2017-10-16
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL12155657235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist