Provider Demographics
NPI:1982248902
Name:COOK, TRACY (LE)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:COOK
Suffix:
Gender:F
Credentials:LE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1533 NEW BRITAIN AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-3378
Mailing Address - Country:US
Mailing Address - Phone:860-678-8200
Mailing Address - Fax:860-678-0368
Practice Address - Street 1:1533 NEW BRITAIN AVE STE 2
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-3378
Practice Address - Country:US
Practice Address - Phone:860-678-8200
Practice Address - Fax:860-678-0368
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-02
Last Update Date:2019-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000525174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist