Provider Demographics
NPI:1407371586
Name:COOPER, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:COOPER
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 1:1681 BLAKELY RD
Mailing Address - Street 2:
Mailing Address - City:SALTERS
Mailing Address - State:SC
Mailing Address - Zip Code:29590-3437
Mailing Address - Country:US
Mailing Address - Phone:843-687-6641
Mailing Address - Fax:
Practice Address - Street 1:1253 GAUSETOWN RD
Practice Address - Street 2:
Practice Address - City:KINGSTREE
Practice Address - State:SC
Practice Address - Zip Code:29556-7491
Practice Address - Country:US
Practice Address - Phone:843-382-7641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-09
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC30392355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant