Basic Information
| Provider Information | |||||||||
| NPI: | 1235542895 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRACEY | ||||||||
| FirstName: | KRISTA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | M.A., SLP-CCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 E 2ND ST | ||||||||
| Address2: | |||||||||
| City: | RICHLAND CENTER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535811914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086476321 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 333 E 2ND ST | ||||||||
| Address2: | |||||||||
| City: | RICHLAND CENTER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535811914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086476321 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2014 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 9294 | MN | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 4073-154 | WI | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.