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General NPI Number Information
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NPI Number | 1629381728
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Entity Type | Organization
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Legal Business Name | MARY R. STOCK, PHD, LCSW, LLC
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Dates
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Enumeration Date | 07/17/2010
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Last Update Date | 07/17/2010
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Provider Practice Location Address
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Address Line | 4423 LEISURE TIME DR
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City | DIAMONDHEAD
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State | MS
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Zip | 39525-3221
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Country | US
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Telephone | 228-216-0130
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1144
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City | KILN
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State | MS
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Zip | 39556-1144
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Country | US
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Telephone | 228-216-0130
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Fax |
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Authorized Official
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Title or Position | LICENSED CLINICAL SOCIAL WORKER
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Name | MARY R STOCK
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Credential | PHD, LCSW
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Telephone | 228-216-0130
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | C2936
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License Number State | MS
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