Provider Demographics
NPI:1265976211
Name:KELLERSBERGER, TRACY MARIE
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:MARIE
Last Name:KELLERSBERGER
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 1:1223 N 1120 W
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:UT
Mailing Address - Zip Code:84015-8834
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1133 N MAIN ST STE 206
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-4875
Practice Address - Country:US
Practice Address - Phone:801-689-7459
Practice Address - Fax:801-543-3330
Is Sole Proprietor?:No
Enumeration Date:2016-12-09
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9129313-4102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist