Provider Demographics
NPI:1699813097
Name:IRENE, TRACEY A (AUD)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:A
Last Name:IRENE
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N67W23421 NANCY DR
Mailing Address - Street 2:
Mailing Address - City:SUSSEX
Mailing Address - State:WI
Mailing Address - Zip Code:53089-2786
Mailing Address - Country:US
Mailing Address - Phone:262-820-0371
Mailing Address - Fax:
Practice Address - Street 1:1111 DELAFIELD ST
Practice Address - Street 2:SUITE 102
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3417
Practice Address - Country:US
Practice Address - Phone:262-549-5150
Practice Address - Fax:262-549-1337
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI303-156231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41135900Medicaid