Provider Demographics
NPI:1558646448
Name:LITTLE, TRACEY D (LCSW, CASAC)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:D
Last Name:LITTLE
Suffix:
Gender:F
Credentials:LCSW, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20417 HILLSIDE AVE
Mailing Address - Street 2:SUITE 332
Mailing Address - City:HOLLIS
Mailing Address - State:NY
Mailing Address - Zip Code:11423-2213
Mailing Address - Country:US
Mailing Address - Phone:718-926-5462
Mailing Address - Fax:718-464-1558
Practice Address - Street 1:11835 QUEENS BLVD
Practice Address - Street 2:STE 400
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-7200
Practice Address - Country:US
Practice Address - Phone:718-926-5462
Practice Address - Fax:718-464-1558
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-11
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY17106101YA0400X
NY083223-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)