Provider Demographics
NPI:1720499148
Name:CACCAVALE, TRACIE (PHD)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:CACCAVALE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 QUANNACUT RD
Mailing Address - Street 2:
Mailing Address - City:PINE BUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12566-5431
Mailing Address - Country:US
Mailing Address - Phone:845-873-0104
Mailing Address - Fax:
Practice Address - Street 1:78 QUANNACUT RD
Practice Address - Street 2:
Practice Address - City:PINE BUSH
Practice Address - State:NY
Practice Address - Zip Code:12566-5431
Practice Address - Country:US
Practice Address - Phone:845-873-0104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-20
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021270103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical