Provider Demographics
NPI:1326505769
Name:TUCKER, TRACI LEREE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:LEREE
Last Name:TUCKER
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:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:SALINA
Mailing Address - State:OK
Mailing Address - Zip Code:74365-0098
Mailing Address - Country:US
Mailing Address - Phone:918-434-5135
Mailing Address - Fax:
Practice Address - Street 1:212 E FERRY ST
Practice Address - Street 2:
Practice Address - City:SALINA
Practice Address - State:OK
Practice Address - Zip Code:74365-2622
Practice Address - Country:US
Practice Address - Phone:918-434-5135
Practice Address - Fax:918-434-8998
Is Sole Proprietor?:No
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
09144942235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist