Provider Demographics
NPI:1285958504
Name:ANDERSON, TRACY M
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:M
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:TRACY
Other - Middle Name:A
Other - Last Name:MULLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SPL
Mailing Address - Street 1:1012 TABOR PL
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-3642
Mailing Address - Country:US
Mailing Address - Phone:315-797-1398
Mailing Address - Fax:
Practice Address - Street 1:1012 TABOR PL
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-3642
Practice Address - Country:US
Practice Address - Phone:315-797-1398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-15
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014898-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00313539Medicaid
NY01815443Medicaid
NY01815443Medicaid
NY334526Medicare Oscar/Certification