Provider Demographics
NPI:1720685878
Name:VICK, ANNE MARIE (R-DMT)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:MARIE
Last Name:VICK
Suffix:
Gender:F
Credentials:R-DMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:483 CLERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-2253
Mailing Address - Country:US
Mailing Address - Phone:718-643-5300
Mailing Address - Fax:
Practice Address - Street 1:483 CLERMONT AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-2253
Practice Address - Country:US
Practice Address - Phone:718-643-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP107084225600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP107084Medicaid