Healthcare Provider Details

I. General information

NPI: 1043562846
Provider Name (Legal Business Name): GALE ELIZABETH TRACER MA CCC/SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GALE ELIZABETH GRAHAM

II. Dates (important events)

Enumeration Date: 10/04/2012
Last Update Date: 10/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31741 RANCHO VIEJO RD
SAN JUAN CAPISTRANO CA
92675-6722
US

IV. Provider business mailing address

2222 SULLIVAN TRL
EASTON PA
18040-7958
US

V. Phone/Fax

Practice location:
  • Phone: 949-248-8855
  • Fax: 949-667-0205
Mailing address:
  • Phone: 800-944-9782
  • Fax: 610-438-2046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP3262
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: