Provider Demographics
NPI:1407457732
Name:MADDOCK, OLIVIA (LAC)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:MADDOCK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-6544
Mailing Address - Country:US
Mailing Address - Phone:315-879-7416
Mailing Address - Fax:
Practice Address - Street 1:84 SWEENEY ST STE 1
Practice Address - Street 2:
Practice Address - City:NORTH TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14120-5822
Practice Address - Country:US
Practice Address - Phone:716-694-2225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006810171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist