Provider Demographics
NPI:1144642695
Name:DOMENECH, TRACIE (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:TRACIE
Middle Name:
Last Name:DOMENECH
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5266 S ANDES CT
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80015-4896
Mailing Address - Country:US
Mailing Address - Phone:720-879-1612
Mailing Address - Fax:
Practice Address - Street 1:3540 S POPLAR ST STE 101
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80237-1365
Practice Address - Country:US
Practice Address - Phone:303-488-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-16
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO121235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist