Provider Demographics
NPI:1003372012
Name:SPITZACK, TRACY (SLP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:SPITZACK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:MUELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:12450 CLOUD DR NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-6274
Mailing Address - Country:US
Mailing Address - Phone:763-777-7117
Mailing Address - Fax:651-401-0598
Practice Address - Street 1:12450 CLOUD DR NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-6274
Practice Address - Country:US
Practice Address - Phone:763-777-7117
Practice Address - Fax:651-401-0598
Is Sole Proprietor?:No
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9902235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist