Provider Demographics
NPI:1194903047
Name:ROBINSON, TRACY (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:
Last Name:ROBINSON
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 1:1606 CENTRAL TRAILS DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-6358
Mailing Address - Country:US
Mailing Address - Phone:901-230-4211
Mailing Address - Fax:662-349-3433
Practice Address - Street 1:291 E COMMERCE ST
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:MS
Practice Address - Zip Code:38632-2323
Practice Address - Country:US
Practice Address - Phone:662-298-0066
Practice Address - Fax:662-298-0067
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-02
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS2854235Z00000X
TNSP2911235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06009569Medicaid