Provider Demographics
NPI:1447724133
Name:GREENWOOD, TRACEY J (MS-SLP/L)
Entity type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:J
Last Name:GREENWOOD
Suffix:
Gender:F
Credentials:MS-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 SUNSET RD
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-2642
Mailing Address - Country:US
Mailing Address - Phone:309-258-8190
Mailing Address - Fax:
Practice Address - Street 1:800 W ROMEO B GARRETT AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61605-2207
Practice Address - Country:US
Practice Address - Phone:309-672-6810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL288330235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL288330OtherSTATE OF ILLINOIS LICENSE