Provider Demographics
NPI:1104539782
Name:PURDY, TRACY MARIE (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:MARIE
Last Name:PURDY
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 N STEVENSON CT
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-9668
Mailing Address - Country:US
Mailing Address - Phone:626-222-0040
Mailing Address - Fax:
Practice Address - Street 1:545 N GARDEN PLZ
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-6465
Practice Address - Country:US
Practice Address - Phone:626-222-0040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-28
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASLP-5340235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist