Provider Demographics
NPI:1538565841
Name:ROBERTS, TRACEY (LAC)
Entity type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10006-1518
Mailing Address - Country:US
Mailing Address - Phone:917-538-2080
Mailing Address - Fax:
Practice Address - Street 1:123 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10006-1518
Practice Address - Country:US
Practice Address - Phone:917-538-2080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-13
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005353171100000X
RIDA00431171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist