Provider Demographics
NPI:1386844041
Name:EDMOND, TRACEY (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:
Last Name:EDMOND
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 1:17150 BURNET ST
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-6839
Mailing Address - Country:US
Mailing Address - Phone:262-754-6782
Mailing Address - Fax:
Practice Address - Street 1:316 N MILWAUKEE ST
Practice Address - Street 2:SUITE 208
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-5885
Practice Address - Country:US
Practice Address - Phone:888-389-9030
Practice Address - Fax:888-389-9031
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-20
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1485-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist