1558646448 NPI number — TRACEY D LITTLE LCSW, CASAC

Table of content: TRACEY D LITTLE LCSW, CASAC (NPI 1558646448)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558646448 NPI number — TRACEY D LITTLE LCSW, CASAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LITTLE
Provider First Name:
TRACEY
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW, CASAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558646448
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20417 HILLSIDE AVE
Provider Second Line Business Mailing Address:
SUITE 332
Provider Business Mailing Address City Name:
HOLLIS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11423-2213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-926-5462
Provider Business Mailing Address Fax Number:
718-464-1558

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11835 QUEENS BLVD
Provider Second Line Business Practice Location Address:
STE 400
Provider Business Practice Location Address City Name:
FOREST HILLS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11375-7200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-926-5462
Provider Business Practice Location Address Fax Number:
718-464-1558
Provider Enumeration Date:
10/11/2011

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: 101YA0400X , with the licence number:  17106 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 083223-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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