Provider Demographics
NPI:1972778504
Name:CARPENTER, TRACEY O (MCD,CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:O
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:MCD,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3140 SONYA ST
Mailing Address - Street 2:
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-9553
Mailing Address - Country:US
Mailing Address - Phone:850-995-3201
Mailing Address - Fax:
Practice Address - Street 1:3140 SONYA ST
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-9553
Practice Address - Country:US
Practice Address - Phone:850-995-3201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA2553235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL882456800Medicaid