MEDICARE: MS. TRACEY E KOCK ITDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	007369	SC
2	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1558624312
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TRACEY E KOCK ITDS

Provider Business Mailing Address
First Line	:	21113 LAKE TALIA BLVD
Second Line	:
City	:	LAND O LAKES
State	:	FL
Zip	:	34638-3738
Country	:	US
Telephone Number	:	813-873-1936
Fax Number	:	813-873-8837

Provider Business Practice Location Address
First Line	:	21113 LAKE TALIA BLVD
Second Line	:
City	:	LAND O LAKES
State	:	FL
Zip	:	34638-3738
Country	:	US
Telephone Number	:	813-873-1936
Fax Number	:	813-873-8837

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/18/2012
Last Update Date	:	06/18/2012

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