Provider Demographics
NPI:1316246952
Name:TYRA, TRACEY LYN (CCC/SLP)
Entity type:Individual
Prefix:MISS
First Name:TRACEY
Middle Name:LYN
Last Name:TYRA
Suffix:
Gender:F
Credentials:CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 SENECA AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-1515
Mailing Address - Country:US
Mailing Address - Phone:585-266-0331
Mailing Address - Fax:585-336-5576
Practice Address - Street 1:301 SENECA AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-1515
Practice Address - Country:US
Practice Address - Phone:585-266-0331
Practice Address - Fax:585-336-5576
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-22
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010252-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist