Provider Demographics
NPI:1265646087
Name:CULLEN, TRACY A (LCSW)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:A
Last Name:CULLEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:NORMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:208 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-1520
Mailing Address - Country:US
Mailing Address - Phone:516-557-5501
Mailing Address - Fax:
Practice Address - Street 1:31 INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-2220
Practice Address - Country:US
Practice Address - Phone:631-924-4411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY074269-1104100000X
NY077204-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker