Provider Demographics
NPI:1467067272
Name:BLACK, TRACY ANN
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:ANN
Last Name:BLACK
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 1:9 BILTOM RD
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10607-2301
Mailing Address - Country:US
Mailing Address - Phone:914-469-5427
Mailing Address - Fax:
Practice Address - Street 1:9 BILTOM RD
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10607-2301
Practice Address - Country:US
Practice Address - Phone:914-469-5427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRBT-14-00147106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician