Provider Demographics
NPI:1558600049
Name:SMITH-KONG, TRACY LYNN (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:LYNN
Last Name:SMITH-KONG
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 13TH ST STE D
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-2246
Mailing Address - Country:US
Mailing Address - Phone:706-780-1704
Mailing Address - Fax:
Practice Address - Street 1:1110 13TH ST STE D
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-2246
Practice Address - Country:US
Practice Address - Phone:888-963-2228
Practice Address - Fax:706-780-1705
Is Sole Proprietor?:No
Enumeration Date:2013-02-04
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
FL1-06-2908103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023206600Medicaid
AL243341Medicaid
GA003205230AMedicaid