Provider Demographics
NPI:1053400614
Name:BURKE, TRACIE POFF (CCC-SLP)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:POFF
Last Name:BURKE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:TRACIE
Other - Middle Name:MARIE
Other - Last Name:POFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:2925 POLO PKWY
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-1453
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13900 HULL STREET RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-2004
Practice Address - Country:US
Practice Address - Phone:804-639-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202004631235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010104696Medicaid