Provider Demographics
NPI:1265931406
Name:CAVEN, TRACY W (MS/CCC-SLP)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:W
Last Name:CAVEN
Suffix:
Gender:F
Credentials:MS/CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5868 BAKER RD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-5903
Mailing Address - Country:US
Mailing Address - Phone:952-767-4200
Mailing Address - Fax:
Practice Address - Street 1:2101 ROLLING GREEN LN
Practice Address - Street 2:
Practice Address - City:NORTH MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56003-4442
Practice Address - Country:US
Practice Address - Phone:507-385-1997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-02
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9843235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN9843OtherMINNESOTA LICENSE