Healthcare Provider Details

I. General information

NPI: 1689168247
Provider Name (Legal Business Name): LEAH SHROCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2018
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 S LEMON AVE # 9892
WALNUT CA
91789-2706
US

IV. Provider business mailing address

340 S LEMON AVE # 9892
WALNUT CA
91789-2706
US

V. Phone/Fax

Practice location:
  • Phone: 415-403-2156
  • Fax:
Mailing address:
  • Phone: 415-403-2156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number096704
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: