Provider Demographics
NPI:1851925762
Name:DAMRAU, TRACEY MARIE
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:MARIE
Last Name:DAMRAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:MARIE
Other - Last Name:LAUDONIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7000 AUSTIN ST
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-1022
Mailing Address - Country:US
Mailing Address - Phone:631-478-8030
Mailing Address - Fax:
Practice Address - Street 1:879 OLD MEDFORD AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-2660
Practice Address - Country:US
Practice Address - Phone:631-478-8030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-29
Last Update Date:2020-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0365527104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker