Provider Demographics
NPI:1023294824
Name:SIEBOLD, TRACEY L (M,S, CCC/SLP, CED)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:L
Last Name:SIEBOLD
Suffix:
Gender:F
Credentials:M,S, CCC/SLP, CED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 271416
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78427-1416
Mailing Address - Country:US
Mailing Address - Phone:361-334-1136
Mailing Address - Fax:
Practice Address - Street 1:4202 HERMOSA DR
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-4535
Practice Address - Country:US
Practice Address - Phone:361-728-9192
Practice Address - Fax:361-334-1136
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-11
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19676235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1023294824Medicaid