Healthcare Provider Details

I. General information

NPI: 1740566850
Provider Name (Legal Business Name): TRACY LEE HOTHERSALL MS, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2011
Last Update Date: 11/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 EDGEWOOD DR
WESTBURY NY
11590-5409
US

IV. Provider business mailing address

20 MANETTO RD
FARMINGDALE NY
11735-2339
US

V. Phone/Fax

Practice location:
  • Phone: 516-608-6489
  • Fax:
Mailing address:
  • Phone: 516-249-1460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number011556
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: