Provider Demographics
NPI:1316186190
Name:BOCK, AVIVA M (OTR)
Entity Type:Individual
Prefix:
First Name:AVIVA
Middle Name:M
Last Name:BOCK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:589 BARNARD AVENUE
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598
Mailing Address - Country:US
Mailing Address - Phone:516-524-2564
Mailing Address - Fax:516-295-1646
Practice Address - Street 1:589 BARNARD AVE
Practice Address - Street 2:
Practice Address - City:WOODMERE
Practice Address - State:NY
Practice Address - Zip Code:11598-2709
Practice Address - Country:US
Practice Address - Phone:516-524-2564
Practice Address - Fax:516-295-1646
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007022-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist