Provider Demographics
NPI:1700023892
Name:LEBLANC, TRACIE KIRSTEN (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:TRACIE
Middle Name:KIRSTEN
Last Name:LEBLANC
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 1:2379 W DUSTY WREN DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-7031
Mailing Address - Country:US
Mailing Address - Phone:602-481-9202
Mailing Address - Fax:
Practice Address - Street 1:2379 W DUSTY WREN DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-7031
Practice Address - Country:US
Practice Address - Phone:602-481-9202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-12
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP1855235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist