Provider Demographics
NPI:1780971457
Name:MISHCON, TRACY ANN (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:ANN
Last Name:MISHCON
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 1:11721 NW 37TH PLACE
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323
Mailing Address - Country:US
Mailing Address - Phone:954-822-0431
Mailing Address - Fax:
Practice Address - Street 1:11721 NW 37TH PL
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-2695
Practice Address - Country:US
Practice Address - Phone:954-822-0431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-01
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 8034235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist