Provider Demographics
NPI:1215339197
Name:DEROLLER, TRACY
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:DEROLLER
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 1:198 ABBEYWALK LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-8428
Mailing Address - Country:US
Mailing Address - Phone:585-474-2796
Mailing Address - Fax:
Practice Address - Street 1:198 ABBEYWALK LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-8428
Practice Address - Country:US
Practice Address - Phone:585-474-2796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-22
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5591235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist