Basic Information
| Provider Information | |||||||||
| NPI: | 1447340377 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOCK | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 406153 | ||||||||
| Address2: | SUITE 305 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303846153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703444327 | ||||||||
| FaxNumber: | 5703447822 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 ADAMS AVE | ||||||||
| Address2: | SUITE 305 | ||||||||
| City: | SCRANTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 185102025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703444327 | ||||||||
| FaxNumber: | 5703447822 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 01/15/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | AT000199L | PA | Y | Speech, Language and Hearing Service Providers | Audiologist | 174400000X | AT000199L | PA | N | Other Service Providers | Specialist | 231HA2400X | AT000199L | PA | N | Speech, Language and Hearing Service Providers | Audiologist | Assistive Technology Practitioner | 231HA2500X | AT000199L | PA | N | Speech, Language and Hearing Service Providers | Audiologist | Assistive Technology Supplier | 237600000X | AT000199L | PA | N | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 332S00000X | AT000199L | PA | N | Suppliers | Hearing Aid Equipment |
ID Information
| ID | Type | State | Issuer | Description | 0012749680001 | 05 | PA | MEDICAID | 282868 | 01 | PA | BLUE SHIELD PROVIDER ID | OTHER | AT000199L | 01 | PA | LICENSE NUMBER | OTHER |