Provider Demographics
NPI:1932344579
Name:ANDERSON, TRACEY E (BC-HIS)
Entity Type:Individual
Prefix:MR
First Name:TRACEY
Middle Name:E
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 E SUNSET RD
Mailing Address - Street 2:UNIT 5-260
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-3511
Mailing Address - Country:US
Mailing Address - Phone:702-798-0113
Mailing Address - Fax:866-291-5242
Practice Address - Street 1:16681 MCGREGOR BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3830
Practice Address - Country:US
Practice Address - Phone:239-482-6350
Practice Address - Fax:239-482-6347
Is Sole Proprietor?:No
Enumeration Date:2008-12-11
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS2679237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist