Provider Demographics
NPI:1568504884
Name:DALY-GOLDBERG, TRACEY STAR (OTR L)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:STAR
Last Name:DALY-GOLDBERG
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4030 E AGAVE RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-0608
Mailing Address - Country:US
Mailing Address - Phone:480-239-0553
Mailing Address - Fax:
Practice Address - Street 1:4030 E AGAVE RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-0608
Practice Address - Country:US
Practice Address - Phone:480-239-0553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3114225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ795817Medicaid