Healthcare Provider Details

I. General information

NPI: 1487959938
Provider Name (Legal Business Name): JOHN TRACY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2011
Last Update Date: 09/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 W. ADAMS BLVD
LOS ANGELES CA
90018-2039
US

IV. Provider business mailing address

2160 W. ADAMS BLVD
LOS ANGELES CA
90018-2039
US

V. Phone/Fax

Practice location:
  • Phone: 213-748-5481
  • Fax: 213-749-1651
Mailing address:
  • Phone: 213-748-5481
  • Fax: 213-749-1651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number191801651
License Number StateCA

VIII. Authorized Official

Name: CATHLEEN MARY MATHES
Title or Position: PRESIDENT & CEO
Credential: M.S.ED, LSLS
Phone: 213-748-5481