Provider Demographics
NPI:1700349081
Name:BOREJDO, TRACY EDENSON (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:EDENSON
Last Name:BOREJDO
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 1:4200 MCKINNEY AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-4526
Mailing Address - Country:US
Mailing Address - Phone:972-749-6500
Mailing Address - Fax:
Practice Address - Street 1:12225 GREENVILLE AVE # 600
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-9362
Practice Address - Country:US
Practice Address - Phone:866-575-9820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-12
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105605235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist