Provider Demographics
NPI:1497099295
Name:CLARK-CHERRY, TRACY (LMT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:CLARK-CHERRY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 HORSENDEN RD
Mailing Address - Street 2:
Mailing Address - City:NEW PALTZ
Mailing Address - State:NY
Mailing Address - Zip Code:12561-3132
Mailing Address - Country:US
Mailing Address - Phone:845-706-6692
Mailing Address - Fax:
Practice Address - Street 1:10 MAIN ST
Practice Address - Street 2:MOSAIC BODYWORKS, WATER STREET MARKET, SUITE 325
Practice Address - City:NEW PALTZ
Practice Address - State:NY
Practice Address - Zip Code:12561-1762
Practice Address - Country:US
Practice Address - Phone:845-706-6692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-16
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005315-2225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist