Provider Demographics
NPI:1477621704
Name:THEOTOKAS, TRACIE MICHELLE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:TRACIE
Middle Name:MICHELLE
Last Name:THEOTOKAS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 NIELSON ST
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-7029
Mailing Address - Country:US
Mailing Address - Phone:212-681-0383
Mailing Address - Fax:
Practice Address - Street 1:318 NIELSON ST
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-7029
Practice Address - Country:US
Practice Address - Phone:212-681-0383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY074639-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker