Provider Demographics
NPI:1528379963
Name:DONZIS, TRACIE DAWN (MA, CCC, SLP)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:DAWN
Last Name:DONZIS
Suffix:
Gender:F
Credentials:MA, CCC, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 ASH DR
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-2208
Mailing Address - Country:US
Mailing Address - Phone:516-996-9618
Mailing Address - Fax:
Practice Address - Street 1:110 ASH DR
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-2208
Practice Address - Country:US
Practice Address - Phone:516-996-9618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-30
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019167-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03833130Medicaid