Provider Demographics
NPI:1467261354
Name:WEBER, TRACY BRIANNE (MS)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:BRIANNE
Last Name:WEBER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 RONKONKOMA BLVD
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-3314
Mailing Address - Country:US
Mailing Address - Phone:631-813-5619
Mailing Address - Fax:
Practice Address - Street 1:235 BLUE POINT AVE
Practice Address - Street 2:
Practice Address - City:BLUE POINT
Practice Address - State:NY
Practice Address - Zip Code:11715-1261
Practice Address - Country:US
Practice Address - Phone:631-363-5794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-06
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program