Provider Demographics
NPI:1033562848
Name:SHAW GREEN, TRACY E (MS, SLP)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:E
Last Name:SHAW GREEN
Suffix:
Gender:F
Credentials:MS, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 RAMSEY LN
Mailing Address - Street 2:
Mailing Address - City:RAMONA
Mailing Address - State:CA
Mailing Address - Zip Code:92065-2600
Mailing Address - Country:US
Mailing Address - Phone:760-498-4779
Mailing Address - Fax:
Practice Address - Street 1:1821 RAMSEY LN
Practice Address - Street 2:
Practice Address - City:RAMONA
Practice Address - State:CA
Practice Address - Zip Code:92065-2600
Practice Address - Country:US
Practice Address - Phone:760-498-4779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-16
Last Update Date:2016-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPE 9846235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist