Healthcare Provider Details

I. General information

NPI: 1659652535
Provider Name (Legal Business Name): TRACY LEE DISANTO PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2011
Last Update Date: 09/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 WILLIAM ST
LYONS NY
14489-1550
US

IV. Provider business mailing address

12895 MESSNER RD
SAVANNAH NY
13146-9809
US

V. Phone/Fax

Practice location:
  • Phone: 315-946-2200
  • Fax:
Mailing address:
  • Phone: 315-365-3362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number020266
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: