Provider Demographics
NPI:1932225166
Name:BUCKENDORF, TRACY JEAN (MA)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:JEAN
Last Name:BUCKENDORF
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7735 SW 165TH AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-5856
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10300 SW GREENBURG RD
Practice Address - Street 2:ONE LINCOLN CENTER STE 410
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-5410
Practice Address - Country:US
Practice Address - Phone:503-517-8555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR012774235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist