Provider Demographics
NPI:1568693752
Name:KISNER, TRACY JACLYN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:JACLYN
Last Name:KISNER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1981 MARCUS AVE
Mailing Address - Street 2:SUITE C119
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1038
Mailing Address - Country:US
Mailing Address - Phone:516-390-3525
Mailing Address - Fax:
Practice Address - Street 1:1981 MARCUS AVE
Practice Address - Street 2:SUITE C119
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1038
Practice Address - Country:US
Practice Address - Phone:516-390-3525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-05
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018203103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist