Provider Demographics
NPI:1124649082
Name:DOBUSCH, TRACEY MICHELLE (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:MICHELLE
Last Name:DOBUSCH
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:7155 KELSEY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:KELSEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95451-8024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 LANGE ST
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-3297
Practice Address - Country:US
Practice Address - Phone:707-262-3019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-01
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP9688235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASP9688OtherSPEECH PATHOLOGY LICENSE