Provider Demographics
NPI:1972197051
Name:ROUTH, TRACY (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:ROUTH
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 S LAMRO ST
Mailing Address - Street 2:
Mailing Address - City:WINNER
Mailing Address - State:SD
Mailing Address - Zip Code:57580-1617
Mailing Address - Country:US
Mailing Address - Phone:605-840-0631
Mailing Address - Fax:
Practice Address - Street 1:2651 SOUTH AVE W
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-6405
Practice Address - Country:US
Practice Address - Phone:406-728-9162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-01
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTSLP-SP-LIC-9626235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist