Provider Demographics
NPI:1619411550
Name:BERRY, TRACI DANETTE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:DANETTE
Last Name:BERRY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:DANETTE
Other - Last Name:BERRY-OWENS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5645 CLEARSPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-8289
Mailing Address - Country:US
Mailing Address - Phone:571-236-2667
Mailing Address - Fax:
Practice Address - Street 1:5645 CLEARSPRINGS DR
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-8289
Practice Address - Country:US
Practice Address - Phone:571-236-2667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-12
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202005402235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist