Provider Demographics
NPI:1003973686
Name:CARROLL, TRACY D (MA CCC SLP)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:D
Last Name:CARROLL
Suffix:
Gender:F
Credentials:MA CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 E PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2335
Mailing Address - Country:US
Mailing Address - Phone:559-978-0701
Mailing Address - Fax:559-324-0541
Practice Address - Street 1:5100 N 6TH ST
Practice Address - Street 2:SUITE 115A
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-7514
Practice Address - Country:US
Practice Address - Phone:559-978-0701
Practice Address - Fax:559-324-0541
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP 8121235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist