Provider Demographics
NPI:1689082331
Name:SARDINA, TRACEY
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:
Last Name:SARDINA
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 1:102 MAIN ST APT 3
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-3511
Mailing Address - Country:US
Mailing Address - Phone:617-580-8183
Mailing Address - Fax:
Practice Address - Street 1:102 MAIN ST APT 3
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:MA
Practice Address - Zip Code:02129-3511
Practice Address - Country:US
Practice Address - Phone:617-580-8183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-25
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4200235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist