Provider Demographics
NPI:1053516724
Name:TILTON, TRACY LYNN (PHD)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:TILTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:LYNN
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:858 N FRANKLIN ST APT 501
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-3177
Mailing Address - Country:US
Mailing Address - Phone:312-213-4660
Mailing Address - Fax:
Practice Address - Street 1:65 E WACKER PL
Practice Address - Street 2:2240
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-7296
Practice Address - Country:US
Practice Address - Phone:312-621-9002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TH0100X
IL071007798103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical