Provider Demographics
NPI:1396056537
Name:POWELL, TRACI KAY (MA, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:TRACI
Middle Name:KAY
Last Name:POWELL
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2305 FLEMING DR
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-5115
Mailing Address - Country:US
Mailing Address - Phone:574-817-0178
Mailing Address - Fax:
Practice Address - Street 1:2305 FLEMING DR
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-5115
Practice Address - Country:US
Practice Address - Phone:574-817-0178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-22
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12111817235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist