=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033406863
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACY LYNN MASSARO M.S. S.L.P. T.S.L.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2011
-----------------------------------------------------
Last Update Date | 06/30/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1767 VETERANS HWY STE 22
-----------------------------------------------------
City | ISLANDIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11749-1536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-851-9486
-----------------------------------------------------
Fax | 631-851-9487
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 923 N ERIE AVE
-----------------------------------------------------
City | LINDENHURST
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11757-2116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-748-6992
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 021063-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------