Provider Demographics
NPI:1588183461
Name:KLOCK, ANIIYAH CHRISTINA (LMT/RMT)
Entity Type:Individual
Prefix:
First Name:ANIIYAH
Middle Name:CHRISTINA
Last Name:KLOCK
Suffix:
Gender:F
Credentials:LMT/RMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 ANDERSEN HILL ROAD
Mailing Address - Street 2:
Mailing Address - City:BERKSHIRE
Mailing Address - State:NY
Mailing Address - Zip Code:13736
Mailing Address - Country:US
Mailing Address - Phone:607-342-3310
Mailing Address - Fax:
Practice Address - Street 1:367 ANDERSEN HILL ROAD
Practice Address - Street 2:
Practice Address - City:BERKSHIRE
Practice Address - State:NY
Practice Address - Zip Code:13736
Practice Address - Country:US
Practice Address - Phone:607-342-3310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-12
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017606225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist