Provider Demographics
NPI:1689718843
Name:HENRY, TRACY L (SLP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:HENRY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 N HAWTHORN DR
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-8440
Mailing Address - Country:US
Mailing Address - Phone:417-326-3183
Mailing Address - Fax:417-325-3184
Practice Address - Street 1:452 S SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-2146
Practice Address - Country:US
Practice Address - Phone:417-326-3183
Practice Address - Fax:417-326-3184
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO102256235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist