Provider Demographics
NPI:1235542895
Name:TRACEY, KRISTA LYNN (MA, SLP-CCC)
Entity type:Individual
Prefix:MRS
First Name:KRISTA
Middle Name:LYNN
Last Name:TRACEY
Suffix:
Gender:F
Credentials:MA, SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:RICHLAND CENTER
Mailing Address - State:WI
Mailing Address - Zip Code:53581-1914
Mailing Address - Country:US
Mailing Address - Phone:608-647-6321
Mailing Address - Fax:
Practice Address - Street 1:333 E 2ND ST
Practice Address - Street 2:
Practice Address - City:RICHLAND CENTER
Practice Address - State:WI
Practice Address - Zip Code:53581-1914
Practice Address - Country:US
Practice Address - Phone:608-647-6321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9294235Z00000X
WI4073-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist