Provider Demographics
NPI:1114198124
Name:JOHANSEN, TRACY (MED CCC SLP)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:
Last Name:JOHANSEN
Suffix:
Gender:F
Credentials:MED CCC SLP
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:GILLIOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1507 BRAMBLE DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27712-1209
Mailing Address - Country:US
Mailing Address - Phone:919-358-2520
Mailing Address - Fax:
Practice Address - Street 1:1507 BRAMBLE DR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27712-1209
Practice Address - Country:US
Practice Address - Phone:919-358-2520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-18
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7785235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist