Provider Demographics
NPI:1770854150
Name:DOHERTY, TRACEY AILEEN (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:AILEEN
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5405 BABCOCK ST NE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-5020
Mailing Address - Country:US
Mailing Address - Phone:321-951-2202
Mailing Address - Fax:321-951-2201
Practice Address - Street 1:5405 BABCOCK ST NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-5020
Practice Address - Country:US
Practice Address - Phone:321-951-2202
Practice Address - Fax:321-951-2201
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-18
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA7922235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist