Provider Demographics
NPI:1508117821
Name:STORTZ, TRACY LYNNE (MSED)
Entity Type:Individual
Prefix:MISS
First Name:TRACY
Middle Name:LYNNE
Last Name:STORTZ
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 J F K LN
Mailing Address - Street 2:
Mailing Address - City:DEPEW
Mailing Address - State:NY
Mailing Address - Zip Code:14043-1827
Mailing Address - Country:US
Mailing Address - Phone:585-344-4404
Mailing Address - Fax:
Practice Address - Street 1:60 J F K LN
Practice Address - Street 2:
Practice Address - City:DEPEW
Practice Address - State:NY
Practice Address - Zip Code:14043-1827
Practice Address - Country:US
Practice Address - Phone:585-344-4404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1190019174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist