Provider Demographics
NPI:1013224773
Name:BRYNELSEN, TRACY JOY (TSLP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:JOY
Last Name:BRYNELSEN
Suffix:
Gender:F
Credentials:TSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 92ND AVE NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-5624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3030 92ND AVE NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-5624
Practice Address - Country:US
Practice Address - Phone:651-269-5055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-01
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP6883235Z00000X
MN8982235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist