Provider Demographics
NPI:1164677357
Name:O'BRIEN-FAY, TRACEY ANN (OT/L)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:ANN
Last Name:O'BRIEN-FAY
Suffix:
Gender:F
Credentials:OT/L
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:ANN
Other - Last Name:O'BRIEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT/L
Mailing Address - Street 1:2536 MOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-1518
Mailing Address - Country:US
Mailing Address - Phone:516-763-1737
Mailing Address - Fax:516-705-0733
Practice Address - Street 1:2536 MOUNT AVE
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-1518
Practice Address - Country:US
Practice Address - Phone:516-763-1737
Practice Address - Fax:516-705-0733
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-01
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004874-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist