Provider Demographics
NPI:1871984195
Name:ROLLER, TRACY NELSON (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:NELSON
Last Name:ROLLER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:MRS
Other - First Name:TRACY
Other - Middle Name:COLE
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:615 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27573-4629
Mailing Address - Country:US
Mailing Address - Phone:336-599-2121
Mailing Address - Fax:336-503-5625
Practice Address - Street 1:615 RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-4629
Practice Address - Country:US
Practice Address - Phone:336-599-2121
Practice Address - Fax:336-503-5625
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-09
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10675235Z00000X
VA2202006887235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC10675OtherSTATE OF NORTH CAROLINA BOARD OF EXAMINERS FOR SPEECH LANG PATHOLOGIST AND AUD
14050523OtherASHA