Provider Demographics
NPI:1023659620
Name:LONG, TRACY JANE (DPT)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:JANE
Last Name:LONG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:DR
Other - First Name:TRACY
Other - Middle Name:JANE
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:219 LITCHFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702-2004
Mailing Address - Country:US
Mailing Address - Phone:631-905-6447
Mailing Address - Fax:
Practice Address - Street 1:887 KELLUM ST
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-1508
Practice Address - Country:US
Practice Address - Phone:631-884-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-04
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043452-1225100000X
NY043452225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist