Provider Demographics
NPI:1699066159
Name:GLEASON, TRACI JAMROGA
Entity type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:JAMROGA
Last Name:GLEASON
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 1:132 OLSEN CT
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:NY
Mailing Address - Zip Code:12549-1736
Mailing Address - Country:US
Mailing Address - Phone:845-649-5784
Mailing Address - Fax:
Practice Address - Street 1:53 GIBSON ROAD
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10925
Practice Address - Country:US
Practice Address - Phone:845-291-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-02
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006919-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant