Provider Demographics
NPI:1659652535
Name:DISANTO, TRACY LEE (PT)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:LEE
Last Name:DISANTO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12895 MESSNER RD
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:NY
Mailing Address - Zip Code:13146-9809
Mailing Address - Country:US
Mailing Address - Phone:315-365-3362
Mailing Address - Fax:
Practice Address - Street 1:98 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:NY
Practice Address - Zip Code:14489-1550
Practice Address - Country:US
Practice Address - Phone:315-946-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020266225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist