Basic Information
| Provider Information | |||||||||
| NPI: | 1811221021 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURGER | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MS, MS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JONES | ||||||||
| OtherFirstName: | TRACY | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2603 | ||||||||
| Address2: | HTN, CLIENT ACCOUNTING | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761132603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175694300 | ||||||||
| FaxNumber: | 8175694517 | ||||||||
| Practice Location | |||||||||
| Address1: | 3840 HULEN ST | ||||||||
| Address2: | HTN | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761077277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175694300 | ||||||||
| FaxNumber: | 8175694517 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2009 | ||||||||
| LastUpdateDate: | 07/17/2013 | ||||||||
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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 | 231H00000X | 51510 | TX | N | Speech, Language and Hearing Service Providers | Audiologist | 235Z00000X | 19092 | TX | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 82S528 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 210765805 | 05 | TX | MEDICAID |