Provider Demographics
NPI:1821374919
Name:GUDENRATH, TRACI DAWN
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:DAWN
Last Name:GUDENRATH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7304 S 169TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68136-4168
Mailing Address - Country:US
Mailing Address - Phone:402-932-3072
Mailing Address - Fax:
Practice Address - Street 1:7304 S 169TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68136-4168
Practice Address - Country:US
Practice Address - Phone:402-932-3072
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
IA001828235Z00000X
NE889235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist