Provider Demographics
NPI:1396287397
Name:DITTMAR, TRACEY
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:DITTMAR
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 1:137 HIDDEN PONDS CIR
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-5233
Mailing Address - Country:US
Mailing Address - Phone:631-780-5662
Mailing Address - Fax:
Practice Address - Street 1:137 HIDDEN PONDS CIR
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-5233
Practice Address - Country:US
Practice Address - Phone:631-780-5662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst