MEDICARE: TRACY W CAVEN MS/CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	9843	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9843	OTHER	MN	MINNESOTA LICENSE

General Provider Information

NPI Number	:	1265931406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACY W CAVEN MS/CCC-SLP

Provider Business Mailing Address
First Line	:	5868 BAKER RD
Second Line	:
City	:	MINNETONKA
State	:	MN
Zip	:	55345-5903
Country	:	US
Telephone Number	:	952-767-4200
Fax Number	:

Provider Business Practice Location Address
First Line	:	2101 ROLLING GREEN LN
Second Line	:
City	:	NORTH MANKATO
State	:	MN
Zip	:	56003-4442
Country	:	US
Telephone Number	:	507-385-1997
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2018
Last Update Date	:	10/26/2022

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