Provider Demographics
NPI:1811300346
Name:MASTORAKIS, TRACIE CAROL
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:CAROL
Last Name:MASTORAKIS
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:TRACIE
Other - Middle Name:CAROL
Other - Last Name:MASTORAKIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:508 AMHERST RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH HADLEY
Mailing Address - State:MA
Mailing Address - Zip Code:01075-1213
Mailing Address - Country:US
Mailing Address - Phone:413-532-4601
Mailing Address - Fax:
Practice Address - Street 1:30 OLD LYMAN RD
Practice Address - Street 2:
Practice Address - City:SOUTH HADLEY
Practice Address - State:MA
Practice Address - Zip Code:01075-2630
Practice Address - Country:US
Practice Address - Phone:413-231-8315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-02
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency