Provider Demographics
NPI:1316070618
Name:GODSHALL, TRACY LEA (MA CCCSLP)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LEA
Last Name:GODSHALL
Suffix:
Gender:F
Credentials:MA CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2131 HENDRICKS STATION RD
Mailing Address - Street 2:
Mailing Address - City:HARLEYSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19438-1315
Mailing Address - Country:US
Mailing Address - Phone:215-234-4208
Mailing Address - Fax:
Practice Address - Street 1:2131 HENDRICKS STATION RD
Practice Address - Street 2:
Practice Address - City:HARLEYSVILLE
Practice Address - State:PA
Practice Address - Zip Code:19438-1315
Practice Address - Country:US
Practice Address - Phone:215-234-4208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL003054L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist