Provider Demographics
NPI:1144483033
Name:WALLACE, TRACEY LYNN (AUD, CCC/A)
Entity type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:LYNN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:AUD, CCC/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6368 COVENTRY WAY
Mailing Address - Street 2:SUITE #146
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-2256
Mailing Address - Country:US
Mailing Address - Phone:301-793-3277
Mailing Address - Fax:
Practice Address - Street 1:14101 MOLLY BERRY RD
Practice Address - Street 2:
Practice Address - City:BRANDYWINE
Practice Address - State:MD
Practice Address - Zip Code:20613-2306
Practice Address - Country:US
Practice Address - Phone:301-793-3277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD00718237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter