Provider Demographics
NPI:1215650007
Name:TRACEY, SIMONE
Entity type:Individual
Prefix:
First Name:SIMONE
Middle Name:
Last Name:TRACEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3031 LUCERNE WAY
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-4248
Mailing Address - Country:US
Mailing Address - Phone:954-849-4085
Mailing Address - Fax:
Practice Address - Street 1:520 NW 165TH ST STE 205
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33169-6343
Practice Address - Country:US
Practice Address - Phone:786-623-4053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11008235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist