Provider Demographics
NPI:1730465865
Name:SAMUELS, TRACEY LYNNE (MED, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:LYNNE
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2472 NW 189TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-5309
Mailing Address - Country:US
Mailing Address - Phone:203-470-2451
Mailing Address - Fax:
Practice Address - Street 1:2833 EXECUTIVE PARK DRIVE
Practice Address - Street 2:SUITE 300
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33331
Practice Address - Country:US
Practice Address - Phone:954-252-8777
Practice Address - Fax:954-389-1990
Is Sole Proprietor?:No
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 10421235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist