Provider Demographics
NPI:1497948921
Name:HUDSON, TRACEY
Entity Type:Individual
Prefix:MR
First Name:TRACEY
Middle Name:
Last Name:HUDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 S 30TH ST
Mailing Address - Street 2:
Mailing Address - City:WYANDANCH
Mailing Address - State:NY
Mailing Address - Zip Code:11798-2711
Mailing Address - Country:US
Mailing Address - Phone:631-491-5988
Mailing Address - Fax:
Practice Address - Street 1:10 EAST GARFIELD STREET
Practice Address - Street 2:APT 2A
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706
Practice Address - Country:US
Practice Address - Phone:631-415-4017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-17
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023024225X00000X
NY006119-1251C00000X
NY023024-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No251C00000XAgenciesDay Training, Developmentally Disabled Services