Provider Demographics
NPI:1275804148
Name:ADAMS, TRACIE NICOLE
Entity Type:Individual
Prefix:MS
First Name:TRACIE
Middle Name:NICOLE
Last Name:ADAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2384 PLACID DR
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-2579
Mailing Address - Country:US
Mailing Address - Phone:850-499-4227
Mailing Address - Fax:
Practice Address - Street 1:8810 CHETWOOD TRACE DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291-5134
Practice Address - Country:US
Practice Address - Phone:850-499-4227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-24
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY139594235Z00000X
OH13972235Z00000X
KYKY 2985235Z00000X
FLSA 8475235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist