Basic Information
| Provider Information | |||||||||
| NPI: | 1255869434 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | DIANE | ||||||||
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| Credential: | M.S. CF-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 51322 | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421025622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707779283 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1609 N DIXIE AVE STE 114 | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427017494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708274652 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 173256 | KY | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.