Provider Demographics
NPI:1942361795
Name:SARRIS, TRACEY L (MSCCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:L
Last Name:SARRIS
Suffix:
Gender:F
Credentials:MSCCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7227 S KINGSWOOD ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-7857
Mailing Address - Country:US
Mailing Address - Phone:812-299-4959
Mailing Address - Fax:812-298-9691
Practice Address - Street 1:7227 S KINGSWOOD ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-7857
Practice Address - Country:US
Practice Address - Phone:812-299-4959
Practice Address - Fax:812-298-9691
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22002247A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200612420Medicaid