Provider Demographics
NPI:1588927321
Name:ERICKSON, TRACY ANN
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:ANN
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 TERRA MAR DR
Mailing Address - Street 2:
Mailing Address - City:HALESITE
Mailing Address - State:NY
Mailing Address - Zip Code:11743-1449
Mailing Address - Country:US
Mailing Address - Phone:631-470-9723
Mailing Address - Fax:
Practice Address - Street 1:14 TERRA MAR DR
Practice Address - Street 2:
Practice Address - City:HALESITE
Practice Address - State:NY
Practice Address - Zip Code:11743
Practice Address - Country:US
Practice Address - Phone:631-470-9723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator