Provider Demographics
NPI:1912300559
Name:KLOSTERMAN, TRACY (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:KLOSTERMAN
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 1:15086 STATE ROUTE 116
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:OH
Mailing Address - Zip Code:45885-9223
Mailing Address - Country:US
Mailing Address - Phone:419-394-5276
Mailing Address - Fax:
Practice Address - Street 1:310 N 2ND ST
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:OH
Practice Address - Zip Code:45828-1242
Practice Address - Country:US
Practice Address - Phone:419-678-2613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-26
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP10096235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist