Provider Demographics
NPI:1275145815
Name:TRACEY, KAITLYN
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:TRACEY
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 1:30 N MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:PORT CHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:10573-4257
Mailing Address - Country:US
Mailing Address - Phone:191-493-9314
Mailing Address - Fax:191-493-9312
Practice Address - Street 1:30 N MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:PORT CHESTER
Practice Address - State:NY
Practice Address - Zip Code:10573-4257
Practice Address - Country:US
Practice Address - Phone:914-939-3143
Practice Address - Fax:914-939-3120
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-17
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024850225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty