Provider Demographics
NPI:1447386479
Name:CONWELL-HENRY, TRACY J (SLP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:J
Last Name:CONWELL-HENRY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:J
Other - Last Name:CONWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:SLP
Mailing Address - Street 1:771 WYNGATE DR W
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-1446
Mailing Address - Country:US
Mailing Address - Phone:516-568-0117
Mailing Address - Fax:
Practice Address - Street 1:1979 MARCUS AVE
Practice Address - Street 2:204
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1002
Practice Address - Country:US
Practice Address - Phone:516-327-4681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006444-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist