Provider Demographics
NPI:1043539901
Name:MADERE, TRACY M (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:M
Last Name:MADERE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14655 PICOU RD
Mailing Address - Street 2:
Mailing Address - City:MAUREPAS
Mailing Address - State:LA
Mailing Address - Zip Code:70449-8265
Mailing Address - Country:US
Mailing Address - Phone:225-695-3895
Mailing Address - Fax:
Practice Address - Street 1:5536 SUPERIOR DR
Practice Address - Street 2:SUITE B
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-6064
Practice Address - Country:US
Practice Address - Phone:225-802-7748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-18
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5870235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist