Provider Demographics
NPI:1902077712
Name:BLACKLOCK, COLLEEN (LAC)
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:
Last Name:BLACKLOCK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 MORGAN AVE
Mailing Address - Street 2:
Mailing Address - City:ONEONTA
Mailing Address - State:NY
Mailing Address - Zip Code:13820-1246
Mailing Address - Country:US
Mailing Address - Phone:607-287-3888
Mailing Address - Fax:
Practice Address - Street 1:46 MORGAN AVE
Practice Address - Street 2:
Practice Address - City:ONEONTA
Practice Address - State:NY
Practice Address - Zip Code:13820-1246
Practice Address - Country:US
Practice Address - Phone:607-432-2211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000977-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist