=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487959938
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN TRACY CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2011
-----------------------------------------------------
Last Update Date | 09/25/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2160 W. ADAMS BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90018-2039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-748-5481
-----------------------------------------------------
Fax | 213-749-1651
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2160 W. ADAMS BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90018-2039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-748-5481
-----------------------------------------------------
Fax | 213-749-1651
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT & CEO
-----------------------------------------------------
Name | CATHLEEN MARY MATHES
-----------------------------------------------------
Credential | M.S.ED, LSLS
-----------------------------------------------------
Telephone | 213-748-5481
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number | 191801651
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------