Provider Demographics
NPI:1659694297
Name:REILLY, TRACY (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:REILLY
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 1:675 CLIFFSIDE DR
Mailing Address - Street 2:
Mailing Address - City:CLARKDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:86324-3142
Mailing Address - Country:US
Mailing Address - Phone:928-525-1599
Mailing Address - Fax:
Practice Address - Street 1:675 CLIFFSIDE DR
Practice Address - Street 2:
Practice Address - City:CLARKDALE
Practice Address - State:AZ
Practice Address - Zip Code:86324-3142
Practice Address - Country:US
Practice Address - Phone:928-525-1599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP6155235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist