Provider Demographics
NPI:1174857890
Name:GREEN, TRACIE A (SLP,CCC)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:A
Last Name:GREEN
Suffix:
Gender:F
Credentials:SLP,CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21550-1518
Mailing Address - Country:US
Mailing Address - Phone:301-334-8900
Mailing Address - Fax:
Practice Address - Street 1:40 S 2ND ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:MD
Practice Address - Zip Code:21550-1518
Practice Address - Country:US
Practice Address - Phone:301-334-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-29
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04797235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD186300200Medicaid
MD186300200Medicaid