Provider Demographics
NPI:1235286378
Name:KING, TRACI JONES (MED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:JONES
Last Name:KING
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 WAX MYRTLE DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31721-6360
Mailing Address - Country:US
Mailing Address - Phone:229-395-6013
Mailing Address - Fax:
Practice Address - Street 1:178 WAX MYRTLE DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31721-6360
Practice Address - Country:US
Practice Address - Phone:229-395-6013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003432235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist