Provider Demographics
NPI:1902241334
Name:O'REILLY, TRACEY F
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:F
Last Name:O'REILLY
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 1:4 LILYPOND LN
Mailing Address - Street 2:
Mailing Address - City:EASTPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11941-1201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2233 NESCONSET HWY
Practice Address - Street 2:SUITE 104
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-1000
Practice Address - Country:US
Practice Address - Phone:631-757-5559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051897104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker