Provider Demographics
NPI:1164606307
Name:THOMSON, TRACIE ANNE (ATC)
Entity Type:Individual
Prefix:MISS
First Name:TRACIE
Middle Name:ANNE
Last Name:THOMSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 WILLIS AVENUE
Mailing Address - Street 2:
Mailing Address - City:FLORAL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11001-1621
Mailing Address - Country:US
Mailing Address - Phone:516-237-8508
Mailing Address - Fax:
Practice Address - Street 1:1 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-4213
Practice Address - Country:US
Practice Address - Phone:516-237-8508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0206020432255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer