Provider Demographics
NPI:1912276148
Name:HEFFERON, TRACY A (COTA)
Entity type:Individual
Prefix:MS
First Name:TRACY
Middle Name:A
Last Name:HEFFERON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 WOODHILLS DR
Mailing Address - Street 2:APT. 204
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-1404
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:53 BEDFORD AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-6414
Practice Address - Country:US
Practice Address - Phone:845-326-1776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-16
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001500-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant