Provider Demographics
NPI:1992249072
Name:HAIDLE, TRACY
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:HAIDLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6700 WASHINGTON AVE S
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3405
Mailing Address - Country:US
Mailing Address - Phone:612-351-1529
Mailing Address - Fax:
Practice Address - Street 1:400 PLAZA CT STE B
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-8261
Practice Address - Country:US
Practice Address - Phone:570-476-6558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-08
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA237600000X
237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter