Provider Demographics
NPI:1750772067
Name:COLLINSWORTH, TRACI HYDRICK (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:HYDRICK
Last Name:COLLINSWORTH
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 1:14057 DUNNBARTON DR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4998
Mailing Address - Country:US
Mailing Address - Phone:228-236-7698
Mailing Address - Fax:
Practice Address - Street 1:14057 DUNNBARTON DR
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-4998
Practice Address - Country:US
Practice Address - Phone:228-236-7698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-09
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3190235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist