Provider Demographics
NPI:1982925731
Name:BLACK, TRACY (SLP)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4168 BREEZEWOOD DR APT 201
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-2468
Mailing Address - Country:US
Mailing Address - Phone:540-616-4525
Mailing Address - Fax:
Practice Address - Street 1:7864 US HWY 117 S
Practice Address - Street 2:
Practice Address - City:ROCKY POINT
Practice Address - State:NC
Practice Address - Zip Code:28457-9458
Practice Address - Country:US
Practice Address - Phone:259-122-4910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-16
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202003640235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist