Provider Demographics
NPI:1003935842
Name:MOCK, MICHELLE (RD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MOCK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 CENTERSHORE RD S
Mailing Address - Street 2:
Mailing Address - City:CENTERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11721-1758
Mailing Address - Country:US
Mailing Address - Phone:631-757-1817
Mailing Address - Fax:
Practice Address - Street 1:525 EAST 68TH STREET
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065
Practice Address - Country:US
Practice Address - Phone:212-746-3520
Practice Address - Fax:212-746-8577
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005610-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered