Provider Demographics
NPI:1588874549
Name:CONDRA, TRACI M (CCC SLP)
Entity type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:M
Last Name:CONDRA
Suffix:
Gender:F
Credentials:CCC SLP
Other - Prefix:MISS
Other - First Name:TRACI
Other - Middle Name:M
Other - Last Name:BRUBAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC/SLP
Mailing Address - Street 1:12160 PEBBLEBROOKE CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-8944
Mailing Address - Country:US
Mailing Address - Phone:317-417-6420
Mailing Address - Fax:
Practice Address - Street 1:12160 PEBBLEBROOKE CT
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46236-8944
Practice Address - Country:US
Practice Address - Phone:317-417-6420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004227A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist