Provider Demographics
NPI:1790014702
Name:MERRICK, KATHLEEN M (LMT)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:M
Last Name:MERRICK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5440 TRINITY AVE
Mailing Address - Street 2:
Mailing Address - City:LOWVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13367-1316
Mailing Address - Country:US
Mailing Address - Phone:315-376-2256
Mailing Address - Fax:
Practice Address - Street 1:5440 TRINITY AVE
Practice Address - Street 2:
Practice Address - City:LOWVILLE
Practice Address - State:NY
Practice Address - Zip Code:13367-1316
Practice Address - Country:US
Practice Address - Phone:315-376-2256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-22
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014969225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist