Provider Demographics
NPI:1033328687
Name:MOSER, TRACY LEE (SLP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LEE
Last Name:MOSER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3564 NW LANSBROOK TER
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-3772
Mailing Address - Country:US
Mailing Address - Phone:503-439-9434
Mailing Address - Fax:
Practice Address - Street 1:6511 NE 18TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-6869
Practice Address - Country:US
Practice Address - Phone:360-759-4917
Practice Address - Fax:360-759-4921
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00002591235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8346579Medicaid