Provider Demographics
NPI:1629304530
Name:DEMARINO, TRACY LYNNE (MS,CCC/SLP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNNE
Last Name:DEMARINO
Suffix:
Gender:F
Credentials:MS,CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:WESTBROOK
Mailing Address - State:ME
Mailing Address - Zip Code:04092-3915
Mailing Address - Country:US
Mailing Address - Phone:207-856-1240
Mailing Address - Fax:
Practice Address - Street 1:300 SPRING ST
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-3915
Practice Address - Country:US
Practice Address - Phone:207-856-1240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-28
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP1173235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432470100Medicaid
ME205068Medicare Oscar/Certification