Provider Demographics
NPI:1538821731
Name:GILMAN, TRACEY (CCC-SLP)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:GILMAN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1142 COUNTY ROAD 146 E
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:TX
Mailing Address - Zip Code:76424-8970
Mailing Address - Country:US
Mailing Address - Phone:817-905-8255
Mailing Address - Fax:
Practice Address - Street 1:907 HWY 183 NORTH
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:TX
Practice Address - Zip Code:76424-7642
Practice Address - Country:US
Practice Address - Phone:254-212-3005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX104447235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist