MEDICARE: MRS. TRACEY CONREY MS

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
1	103K00000X	Behavior Analyst	1-07-3737	FL

General Provider Information

NPI Number	:	1306163167
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TRACEY CONREY MS

Provider Business Mailing Address
First Line	:	2400 S RIDGEWOOD AVE STE 17
Second Line	:
City	:	SOUTH DAYTONA
State	:	FL
Zip	:	32119-3073
Country	:	US
Telephone Number	:	386-492-0988
Fax Number	:	386-402-4327

Provider Business Practice Location Address
First Line	:	2400 S RIDGEWOOD AVE STE 17
Second Line	:
City	:	SOUTH DAYTONA
State	:	FL
Zip	:	32119-3073
Country	:	US
Telephone Number	:	386-492-0988
Fax Number	:	386-233-3313

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2010
Last Update Date	:	02/07/2022

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