Provider Demographics
NPI:1578718177
Name:KLOCK, TRACY NICOLE (MS, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:NICOLE
Last Name:KLOCK
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23172 SWAN RD
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-5372
Mailing Address - Country:US
Mailing Address - Phone:315-955-8684
Mailing Address - Fax:
Practice Address - Street 1:380 GAFFNEY DR
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-1863
Practice Address - Country:US
Practice Address - Phone:315-788-2730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-24
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014240-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist