Provider Demographics
NPI:1083184519
Name:DIRUSSO, TRACEY (PT)
Entity Type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:
Last Name:DIRUSSO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:
Other - Last Name:BURKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3 GROVELAND RD
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-5118
Mailing Address - Country:US
Mailing Address - Phone:617-943-3797
Mailing Address - Fax:
Practice Address - Street 1:127 CAMBRIDGE ST STE 2B
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01803-3735
Practice Address - Country:US
Practice Address - Phone:781-272-2536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-27
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9928225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist