Provider Demographics
NPI:1568767499
Name:GILLETTE, TRACY LEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:LEE
Last Name:GILLETTE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 WEBSTER RD.
Mailing Address - Street 2:
Mailing Address - City:SPENCERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14559
Mailing Address - Country:US
Mailing Address - Phone:585-617-4442
Mailing Address - Fax:585-617-4442
Practice Address - Street 1:115 WEBSTER RD.
Practice Address - Street 2:
Practice Address - City:SPENCERPORT
Practice Address - State:NY
Practice Address - Zip Code:14559
Practice Address - Country:US
Practice Address - Phone:585-617-4442
Practice Address - Fax:585-617-4442
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-25
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004585101YM0800X
SC5050101YP2500X
GALPC006302101YP2500X
GASLP004913235Z00000X
SCSLP3263235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist