Provider Demographics
NPI:1184170516
Name:COOK, TRACEY LEIGH (CCC-SLP)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:LEIGH
Last Name:COOK
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 E ANDRE AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-1868
Mailing Address - Country:US
Mailing Address - Phone:989-444-0094
Mailing Address - Fax:
Practice Address - Street 1:1015 E ANDRE AVE
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-1868
Practice Address - Country:US
Practice Address - Phone:989-444-0094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-26
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101000174235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist