Provider Demographics
NPI:1407070865
Name:EVERETT, TRACI LEE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:LEE
Last Name:EVERETT
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 WORTHINGTON DR
Mailing Address - Street 2:
Mailing Address - City:EXTON
Mailing Address - State:PA
Mailing Address - Zip Code:19341-1648
Mailing Address - Country:US
Mailing Address - Phone:610-363-1256
Mailing Address - Fax:
Practice Address - Street 1:802 WORTHINGTON DR
Practice Address - Street 2:
Practice Address - City:EXTON
Practice Address - State:PA
Practice Address - Zip Code:19341-1648
Practice Address - Country:US
Practice Address - Phone:610-363-1256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL007701235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist