Provider Demographics
NPI:1154544542
Name:GEORGE, TRICIA LYNNETTE (MS,CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:TRICIA
Middle Name:LYNNETTE
Last Name:GEORGE
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 1:27104 PINE BLUFF LN
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:MO
Mailing Address - Zip Code:65658-8381
Mailing Address - Country:US
Mailing Address - Phone:870-715-5359
Mailing Address - Fax:870-505-2016
Practice Address - Street 1:1004 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BERRYVILLE
Practice Address - State:AR
Practice Address - Zip Code:72616-4330
Practice Address - Country:US
Practice Address - Phone:870-715-5359
Practice Address - Fax:870-505-2016
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#1969235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1639440324OtherNPI
AR191773742Medicaid
AR149949721Medicaid