Provider Demographics
NPI:1063735124
Name:BROCK, AHMY LYNN (LMFT)
Entity type:Individual
Prefix:
First Name:AHMY
Middle Name:LYNN
Last Name:BROCK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2997 SWEET RD
Mailing Address - Street 2:
Mailing Address - City:JAMESVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13078-9697
Mailing Address - Country:US
Mailing Address - Phone:315-416-7572
Mailing Address - Fax:315-627-0273
Practice Address - Street 1:5900 N BURDICK ST STE 201
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9463
Practice Address - Country:US
Practice Address - Phone:315-416-7572
Practice Address - Fax:315-627-0273
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-03
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000247-1106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist