Provider Demographics
NPI:1083852214
Name:COLANGELO, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:COLANGELO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:689 NICOLLS RD
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-2725
Mailing Address - Country:US
Mailing Address - Phone:631-300-6153
Mailing Address - Fax:
Practice Address - Street 1:689 NICOLLS RD
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-2725
Practice Address - Country:US
Practice Address - Phone:631-300-6153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-26
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY281474091171W00000X
NY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator