Provider Demographics
NPI:1649817602
Name:TRACEY, MARY ELIZABETH (ND)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:TRACEY
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:FORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:41 SYLVAN AVE
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-4610
Mailing Address - Country:US
Mailing Address - Phone:203-706-5692
Mailing Address - Fax:
Practice Address - Street 1:315 E CENTER ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-5251
Practice Address - Country:US
Practice Address - Phone:860-533-0179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT657175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath