Provider Demographics
NPI:1417398462
Name:JOHNSON, TRACIE LYNN (MS, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:TRACIE
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MS
Other - First Name:TRACIE
Other - Middle Name:LYNN
Other - Last Name:STABLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5533 N GALENA RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61616-4447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5533 N GALENA RD
Practice Address - Street 2:
Practice Address - City:PEORIA HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:61616-4447
Practice Address - Country:US
Practice Address - Phone:309-682-5428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-07
Last Update Date:2013-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146007016235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist