Provider Demographics
NPI:1700497070
Name:THOTTAM, TRACY GEORGE (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:GEORGE
Last Name:THOTTAM
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7612 MIFFLIN KENEDY TER
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-1844
Mailing Address - Country:US
Mailing Address - Phone:832-444-9131
Mailing Address - Fax:
Practice Address - Street 1:3607 MENCHACA RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-5947
Practice Address - Country:US
Practice Address - Phone:512-444-7219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-11
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102335235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist