Provider Demographics
NPI:1184238719
Name:HENRY, TRACI CHRISTINE
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:CHRISTINE
Last Name:HENRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5275 REDTAIL DR
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:MO
Mailing Address - Zip Code:65010-2102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5275 REDTAIL DR
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:MO
Practice Address - Zip Code:65010-2102
Practice Address - Country:US
Practice Address - Phone:573-657-2144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020015522235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist