MEDICARE: JOHN M TRACY PH.D.

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	1245	OR

General Provider Information

NPI Number	:	1730411471
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN M TRACY PH.D.

Provider Business Mailing Address
First Line	:	525 ORCHARD DRIVE WEST
Second Line	:
City	:	MONMOUTH
State	:	OR
Zip	:	97361-1931
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	525 N. SANTIAM HIGHWAY
Second Line	:
City	:	LEBANON
State	:	OR
Zip	:	97355-0739
Country	:	US
Telephone Number	:	541-451-7521
Fax Number	:

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

Provider Enumeration Date	:	02/05/2010
Last Update Date	:	02/05/2010

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Directions to “ JOHN M TRACY PH.D.” Practice Location

Language	Start Address	Practice Location

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