Provider Demographics
NPI:1497222178
Name:WIDRICK, TRACEY J (SLP CCC TSSLD)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:J
Last Name:WIDRICK
Suffix:
Gender:F
Credentials:SLP CCC TSSLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 HUNTERS GLN
Mailing Address - Street 2:
Mailing Address - City:FAR HILLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07931-2215
Mailing Address - Country:US
Mailing Address - Phone:516-376-8396
Mailing Address - Fax:
Practice Address - Street 1:15050 14TH RD
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357-2609
Practice Address - Country:US
Practice Address - Phone:718-767-0071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-31
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist