Provider Demographics
NPI:1487980637
Name:VITULLI, TRACY (LMT, LAC)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:VITULLI
Suffix:
Gender:F
Credentials:LMT, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5931 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-2634
Mailing Address - Country:US
Mailing Address - Phone:631-258-2297
Mailing Address - Fax:
Practice Address - Street 1:250 W 57TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10107-0001
Practice Address - Country:US
Practice Address - Phone:631-258-2297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-22
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022924225700000X
NY004237171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist