Basic Information
| Provider Information | |||||||||
| NPI: | 1871124321 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOCK | ||||||||
| FirstName: | ALIVIA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | AAS, QMHS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WEINER | ||||||||
| OtherFirstName: | ALIVIA | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2845 BELL ST | ||||||||
| Address2: | |||||||||
| City: | ZANESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437011720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404549766 | ||||||||
| FaxNumber: | 7405886452 | ||||||||
| Practice Location | |||||||||
| Address1: | 915 S RIVERSIDE DR NE | ||||||||
| Address2: | |||||||||
| City: | MCCONNELSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437569102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7409625204 | ||||||||
| FaxNumber: | 7409623688 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2020 | ||||||||
| LastUpdateDate: | 02/06/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 0389216 | 05 | OH | MEDICAID |