Provider Demographics
NPI:1699444158
Name:SAN JUAN, TRACI MARKEN (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:MARKEN
Last Name:SAN JUAN
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 1:2018 WHATCOM LN
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98229-2238
Mailing Address - Country:US
Mailing Address - Phone:541-306-8097
Mailing Address - Fax:
Practice Address - Street 1:3400 HOLLYWOOD AVE
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1134
Practice Address - Country:US
Practice Address - Phone:541-306-8097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61090211235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist