Provider Demographics
NPI:1740566850
Name:HOTHERSALL, TRACY LEE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:LEE
Last Name:HOTHERSALL
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 1:20 MANETTO RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-2339
Mailing Address - Country:US
Mailing Address - Phone:516-249-1460
Mailing Address - Fax:
Practice Address - Street 1:740 EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-5409
Practice Address - Country:US
Practice Address - Phone:516-608-6489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011556235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist