Provider Demographics
NPI:1134467004
Name:LOUCKS, CAROL
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:LOUCKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 MOHAWK ST
Mailing Address - Street 2:127 BUILDING 4
Mailing Address - City:LEWISTON
Mailing Address - State:NY
Mailing Address - Zip Code:14092-1481
Mailing Address - Country:US
Mailing Address - Phone:716-754-2616
Mailing Address - Fax:
Practice Address - Street 1:5570 MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-5477
Practice Address - Country:US
Practice Address - Phone:716-541-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-28
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003996-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant