Basic Information
Provider Information | |||||||||
NPI: | 1679772305 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CERASUOLO | ||||||||
FirstName: | TRACY | ||||||||
MiddleName: | RENEE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WELLIVER | ||||||||
OtherFirstName: | TRACY | ||||||||
OtherMiddleName: | RENEE | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MSPT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4 PATRIOTS WAY | ||||||||
Address2: |   | ||||||||
City: | SOUTHWICK | ||||||||
State: | MA | ||||||||
PostalCode: | 010779561 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4135694151 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 464 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | AGAWAM | ||||||||
State: | MA | ||||||||
PostalCode: | 010011826 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4137868000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2007 | ||||||||
LastUpdateDate: | 07/12/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 13066 | MA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.