Provider Demographics
NPI:1912170564
Name:WISE, TRACEY JANE (MS CCC)
Entity Type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:JANE
Last Name:WISE
Suffix:
Gender:F
Credentials:MS CCC
Other - Prefix:MS
Other - First Name:TRACEY
Other - Middle Name:JANE
Other - Last Name:VAUGHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC
Mailing Address - Street 1:6608 FALLEN WOOD LN
Mailing Address - Street 2:
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501-8191
Mailing Address - Country:US
Mailing Address - Phone:715-282-7566
Mailing Address - Fax:
Practice Address - Street 1:702 E KING RD
Practice Address - Street 2:
Practice Address - City:TOMAHAWK
Practice Address - State:WI
Practice Address - Zip Code:54487
Practice Address - Country:US
Practice Address - Phone:715-282-7566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-03
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI503-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI426259000Medicaid