1356558084 NPI number — TRACY ANN DANIELAK MSPT

Table of content: TRACY ANN DANIELAK MSPT (NPI 1356558084)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356558084 NPI number — TRACY ANN DANIELAK MSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DANIELAK
Provider First Name:
TRACY
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MIX
Provider Other First Name:
TRACY
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1356558084
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 CEDAR RUN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAYVILLE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08721-3504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-606-0526
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
340 ATLANTIC CITY BLVD
Provider Second Line Business Practice Location Address:
340 ROUTE 9 PENN FEDERAL PLAZA
Provider Business Practice Location Address City Name:
BAYVILLE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08721-1255
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-361-5500
Provider Business Practice Location Address Fax Number:
973-361-5080
Provider Enumeration Date:
05/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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