Provider Demographics
NPI:1538637699
Name:KRUCK, NICOLE THERESA (LAC, LMT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:THERESA
Last Name:KRUCK
Suffix:
Gender:F
Credentials:LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 E 10TH ST APT 1C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-5931
Mailing Address - Country:US
Mailing Address - Phone:347-628-8595
Mailing Address - Fax:
Practice Address - Street 1:15 E 10TH ST APT 1C
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-5931
Practice Address - Country:US
Practice Address - Phone:917-338-1660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006186171100000X
NY010281225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist