MEDICARE: MRS. TRACY JOHANSEN MED CCC SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	7785	NC

General Provider Information

NPI Number	:	1114198124
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TRACY JOHANSEN MED CCC SLP

Provider Business Mailing Address
First Line	:	1507 BRAMBLE DR
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27712-1209
Country	:	US
Telephone Number	:	919-358-2520
Fax Number	:

Provider Business Practice Location Address
First Line	:	1507 BRAMBLE DR
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27712-1209
Country	:	US
Telephone Number	:	919-358-2520
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/18/2008
Last Update Date	:	04/12/2016

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