Provider Demographics
NPI:1639948383
Name:COOPER, TRACEY LYNN
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:LYNN
Last Name:COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 E MALL DR
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-2308
Mailing Address - Country:US
Mailing Address - Phone:516-375-8851
Mailing Address - Fax:
Practice Address - Street 1:38 E MALL DR
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-2308
Practice Address - Country:US
Practice Address - Phone:516-375-8851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-21
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator