Provider Demographics
NPI:1407240468
Name:GARRISON, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:GARRISON
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 1:142 KADEN CREEK PL
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77316-2126
Mailing Address - Country:US
Mailing Address - Phone:281-650-7220
Mailing Address - Fax:
Practice Address - Street 1:142 KADEN CREEK PL
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:TX
Practice Address - Zip Code:77316-2126
Practice Address - Country:US
Practice Address - Phone:281-650-7220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-26
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102089235Z00000X
01104574235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist