Provider Demographics
NPI:1689644841
Name:COULTON, TRACY (MSPT)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:
Last Name:COULTON
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 GARDENIA AVE
Mailing Address - Street 2:
Mailing Address - City:HAMPTON BAYS
Mailing Address - State:NY
Mailing Address - Zip Code:11946-2823
Mailing Address - Country:US
Mailing Address - Phone:631-283-4190
Mailing Address - Fax:631-283-7650
Practice Address - Street 1:167 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-4823
Practice Address - Country:US
Practice Address - Phone:631-283-4190
Practice Address - Fax:631-283-7650
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012072-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist