Provider Demographics
NPI:1699935171
Name:MILLER, TRACEY LEAVENS (MA CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:LEAVENS
Last Name:MILLER
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 1:1 EMERSON DR
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-3204
Mailing Address - Country:US
Mailing Address - Phone:860-640-6317
Mailing Address - Fax:
Practice Address - Street 1:807 WILBRAHAM RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01109-2067
Practice Address - Country:US
Practice Address - Phone:413-782-1800
Practice Address - Fax:413-782-0800
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004103235Z00000X
MA9216235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist