Provider Demographics
NPI:1669668075
Name:MASCILAK, TRACY L (PT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:MASCILAK
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 1:13 WINDING BROOK RD
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:07419-1026
Mailing Address - Country:US
Mailing Address - Phone:973-670-8627
Mailing Address - Fax:
Practice Address - Street 1:540 LAFAYETTE RD
Practice Address - Street 2:SUITE B
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-3497
Practice Address - Country:US
Practice Address - Phone:973-940-8680
Practice Address - Fax:973-940-8634
Is Sole Proprietor?:No
Enumeration Date:2007-09-19
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00626600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist