Provider Demographics
NPI:1790939296
Name:TRACY, KATHLEEN M (SLP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:TRACY
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 1:1030 DREWVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:NY
Mailing Address - Zip Code:10509-2513
Mailing Address - Country:US
Mailing Address - Phone:845-279-6765
Mailing Address - Fax:
Practice Address - Street 1:1030 DREWVILLE RD
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:NY
Practice Address - Zip Code:10509-2513
Practice Address - Country:US
Practice Address - Phone:845-279-6765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-11
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008196-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist