Provider Demographics
NPI:1447340377
Name:MOCK, STEPHEN E (PHD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:E
Last Name:MOCK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 406153
Mailing Address - Street 2:SUITE 305
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-6153
Mailing Address - Country:US
Mailing Address - Phone:570-344-4327
Mailing Address - Fax:570-344-7822
Practice Address - Street 1:401 ADAMS AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-2025
Practice Address - Country:US
Practice Address - Phone:570-344-4327
Practice Address - Fax:570-344-7822
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAT000199L231H00000X, 174400000X, 231HA2400X, 231HA2500X, 237600000X, 332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No174400000XOther Service ProvidersSpecialist
No231HA2400XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Practitioner
No231HA2500XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Supplier
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No332S00000XSuppliersHearing Aid Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012749680001Medicaid
PA282868OtherBLUE SHIELD PROVIDER ID
PAAT000199LOtherLICENSE NUMBER
PA282868Medicare ID - Type Unspecified
PA0012749680001Medicaid