Provider Demographics
NPI:1497855910
Name:CARLOS, TRACEY LYNN (MS, CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:LYNN
Last Name:CARLOS
Suffix:
Gender:F
Credentials:MS, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13200 W NEWBERRY RD
Mailing Address - Street 2:#D20
Mailing Address - City:NEWBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32669-2764
Mailing Address - Country:US
Mailing Address - Phone:352-494-4478
Mailing Address - Fax:352-331-5605
Practice Address - Street 1:13200 W NEWBERRY RD
Practice Address - Street 2:#D20
Practice Address - City:NEWBERRY
Practice Address - State:FL
Practice Address - Zip Code:32669-2764
Practice Address - Country:US
Practice Address - Phone:352-494-4478
Practice Address - Fax:352-331-5605
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 5433235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist