Provider Demographics
NPI:1730411471
Name:TRACY, JOHN M (PHD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:TRACY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 ORCHARD DRIVE WEST
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:OR
Mailing Address - Zip Code:97361-1931
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:525 N. SANTIAM HIGHWAY
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-0739
Practice Address - Country:US
Practice Address - Phone:541-451-7521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-05
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1245235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist