Healthcare Provider Details

I. General information

NPI: 1386389047
Provider Name (Legal Business Name): KATHERINE E TRACY CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATHERINE E REYNOLDS M.A., CCC-SLP

II. Dates (important events)

Enumeration Date: 04/27/2022
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34607 F50 RD
CRAWFORD CO
81415-8911
US

IV. Provider business mailing address

34607 F50 RD
CRAWFORD CO
81415-8911
US

V. Phone/Fax

Practice location:
  • Phone: 419-707-2348
  • Fax:
Mailing address:
  • Phone: 419-707-2348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP.0004079
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: