Provider Demographics
NPI:1558563528
Name:PERON, TRACY LOUISE (MED)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:LOUISE
Last Name:PERON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4358 RICHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-3938
Mailing Address - Country:US
Mailing Address - Phone:716-649-5472
Mailing Address - Fax:
Practice Address - Street 1:87 MAIN ST
Practice Address - Street 2:
Practice Address - City:SILVER CREEK
Practice Address - State:NY
Practice Address - Zip Code:14136-1448
Practice Address - Country:US
Practice Address - Phone:716-934-4274
Practice Address - Fax:716-934-9129
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool