Provider Demographics
NPI:1619935087
Name:MC DONOUGH, TRACY ANN (MSCCC-SLP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:ANN
Last Name:MC DONOUGH
Suffix:
Gender:F
Credentials:MSCCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 RAMBLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHILI
Mailing Address - State:NY
Mailing Address - Zip Code:14514-1022
Mailing Address - Country:US
Mailing Address - Phone:585-594-5951
Mailing Address - Fax:
Practice Address - Street 1:139 FAIRBANKS RD
Practice Address - Street 2:
Practice Address - City:CHURCHVILLE
Practice Address - State:NY
Practice Address - Zip Code:14428-9782
Practice Address - Country:US
Practice Address - Phone:585-723-2140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012482-01235Z00000X
NY012482-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist