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NPI Code Detail

MEDICARE: TRACY A. CULLEN LCSW

MEDICARE: TRACY A. CULLEN LCSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1104100000XSocial Worker074269-1NY
21041C0700XClinical Social Worker077204-1NY

General Provider Information

NPI Number : 1265646087
Entity Type Code : Individual
Provider Name (Legal Business Name) : TRACY A. CULLEN LCSW
Provider Business Mailing Address
First Line : 208 GRANT ST
Second Line :
City : MASSAPEQUA PARK
State : NY
Zip : 11762-1520
Country : US
Telephone Number : 516-557-5501
Fax Number :
Provider Business Practice Location Address
First Line : 31 INDUSTRIAL BLVD
Second Line :
City : MEDFORD
State : NY
Zip : 11763-2220
Country : US
Telephone Number : 631-924-4411
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/10/2007
Last Update Date : 03/31/2010

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