Provider Demographics
NPI:1932548187
Name:WAGES, TRACY (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:WAGES
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 TROTTER CT
Mailing Address - Street 2:
Mailing Address - City:LUGOFF
Mailing Address - State:SC
Mailing Address - Zip Code:29078-8734
Mailing Address - Country:US
Mailing Address - Phone:803-408-0701
Mailing Address - Fax:803-408-0701
Practice Address - Street 1:5 TROTTER CT
Practice Address - Street 2:
Practice Address - City:LUGOFF
Practice Address - State:SC
Practice Address - Zip Code:29078-8734
Practice Address - Country:US
Practice Address - Phone:803-408-0701
Practice Address - Fax:803-408-0701
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-20
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3641235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0591Medicaid