Provider Demographics
NPI:1154623056
Name:ELLIOTT, TRACY LEIGH (PT)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:LEIGH
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:TRACY
Other - Middle Name:LEIGH
Other - Last Name:WALTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:139 STATE STREET RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-3504
Mailing Address - Country:US
Mailing Address - Phone:315-386-4504
Mailing Address - Fax:315-379-0246
Practice Address - Street 1:139 STATE STREET RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-3504
Practice Address - Country:US
Practice Address - Phone:315-386-4504
Practice Address - Fax:315-379-0246
Is Sole Proprietor?:No
Enumeration Date:2010-11-28
Last Update Date:2010-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00863212251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics