Provider Demographics
NPI:1518234749
Name:SANTORE-GOODMAN, TRACY (MS CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:
Last Name:SANTORE-GOODMAN
Suffix:
Gender:F
Credentials:MS CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 ENGLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:EAST GREENBUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12061-3900
Mailing Address - Country:US
Mailing Address - Phone:518-207-2680
Mailing Address - Fax:
Practice Address - Street 1:29 ENGLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:EAST GREENBUSH
Practice Address - State:NY
Practice Address - Zip Code:12061-3900
Practice Address - Country:US
Practice Address - Phone:518-207-2680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01409145Medicaid