Provider Demographics
NPI:1578933529
Name:DAIGLE, TRACI
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:DAIGLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9108 RIDGELY AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-7553
Mailing Address - Country:US
Mailing Address - Phone:817-455-4779
Mailing Address - Fax:
Practice Address - Street 1:6520 43RD ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79407-1941
Practice Address - Country:US
Practice Address - Phone:866-368-6565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-03
Last Update Date:2015-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101392235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist