Provider Demographics
NPI:1023284965
Name:TIMBLE, TRACY (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:TIMBLE
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:CHUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:225 MADERA ST
Mailing Address - Street 2:
Mailing Address - City:LOS OSOS
Mailing Address - State:CA
Mailing Address - Zip Code:93402-4206
Mailing Address - Country:US
Mailing Address - Phone:408-307-1694
Mailing Address - Fax:
Practice Address - Street 1:225 MADERA ST
Practice Address - Street 2:
Practice Address - City:LOS OSOS
Practice Address - State:CA
Practice Address - Zip Code:93402-4206
Practice Address - Country:US
Practice Address - Phone:408-307-1694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-30
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP17304235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist