Provider Demographics
NPI:1447914007
Name:JOHNSON, TRACY CAMILLE (MS, CCC-SLP, CLC)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:CAMILLE
Last Name:JOHNSON
Suffix:
Gender:
Credentials:MS, CCC-SLP, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7302 CRYSTALBROOK DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78724-3313
Mailing Address - Country:US
Mailing Address - Phone:708-537-3136
Mailing Address - Fax:512-222-4330
Practice Address - Street 1:7302 CRYSTALBROOK DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78724-3313
Practice Address - Country:US
Practice Address - Phone:708-537-3136
Practice Address - Fax:512-222-4330
Is Sole Proprietor?:No
Enumeration Date:2021-10-28
Last Update Date:2025-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
352442174N00000X
TX117491235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117491OtherTDLR- SLP
1414916OtherASHA- CCC