Basic Information
| Provider Information | |||||||||
| NPI: | 1053648519 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOCK | ||||||||
| FirstName: | SUSANNE | ||||||||
| MiddleName: | DERR | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CONTINO | ||||||||
| OtherFirstName: | SUZANNE | ||||||||
| OtherMiddleName: | DERR | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 108 MERRYHILL ST | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457501366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
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| Practice Location | |||||||||
| Address1: | 207 COLEGATE DR | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457502363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403760930 | ||||||||
| FaxNumber: | 7403760933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2009 | ||||||||
| LastUpdateDate: | 11/04/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S.0029273 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.