Provider Demographics
NPI:1821198326
Name:SULLIVAN, TRACY L (MA, CCC-A)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:L
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MA, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 1ST ST NW
Mailing Address - Street 2:
Mailing Address - City:LE MARS
Mailing Address - State:IA
Mailing Address - Zip Code:51031-3507
Mailing Address - Country:US
Mailing Address - Phone:712-546-4723
Mailing Address - Fax:
Practice Address - Street 1:13 2ND ST SW
Practice Address - Street 2:
Practice Address - City:LE MARS
Practice Address - State:IA
Practice Address - Zip Code:51031-2007
Practice Address - Country:US
Practice Address - Phone:712-546-4723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00512231H00000X
MN7228231H00000X
IA00788237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist