Provider Demographics
NPI:1295385706
Name:SMITH, TRACEY ANN (SLP)
Entity Type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3610 JACK CULLEN DR
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-2533
Mailing Address - Country:US
Mailing Address - Phone:903-490-3483
Mailing Address - Fax:
Practice Address - Street 1:6101 N STATE LINE AVE
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-5309
Practice Address - Country:US
Practice Address - Phone:903-791-2270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-17
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116253235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist