Provider Demographics
NPI:1952874125
Name:SHIELDS, TRACY ANN (MA,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:ANN
Last Name:SHIELDS
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 1:558 S HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-5909
Mailing Address - Country:US
Mailing Address - Phone:314-276-0071
Mailing Address - Fax:
Practice Address - Street 1:4005 RIPA AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63125-2378
Practice Address - Country:US
Practice Address - Phone:314-544-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO111684235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist