Provider Demographics
NPI:1013386085
Name:CLARK, TRACY ANN (HAS)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:HAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3389 W WOOLBRIGHT RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436-7245
Mailing Address - Country:US
Mailing Address - Phone:561-577-3651
Mailing Address - Fax:561-737-8999
Practice Address - Street 1:3389 W WOOLBRIGHT RD
Practice Address - Street 2:SUITE A
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33436-7245
Practice Address - Country:US
Practice Address - Phone:561-577-3651
Practice Address - Fax:561-737-8999
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-21
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS4778237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist