Basic Information
| Provider Information | |||||||||
| NPI: | 1871984195 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROLLER | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | NELSON | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NELSON | ||||||||
| OtherFirstName: | TRACY | ||||||||
| OtherMiddleName: | COLE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CCC-SLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 615 RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | ROXBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275734629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365992121 | ||||||||
| FaxNumber: | 3365035625 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | ROXBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275734629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365992121 | ||||||||
| FaxNumber: | 3365035625 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2015 | ||||||||
| LastUpdateDate: | 02/09/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 10675 | NC | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 2202006887 | VA | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 10675 | 01 | NC | STATE OF NORTH CAROLINA BOARD OF EXAMINERS FOR SPEECH LANG PATHOLOGIST AND AUD | OTHER | 14050523 | 01 | ASHA | OTHER |