Provider Demographics
NPI:1871124321
Name:MOCK, ALIVIA L (AAS, QMHS)
Entity type:Individual
Prefix:
First Name:ALIVIA
Middle Name:L
Last Name:MOCK
Suffix:
Gender:F
Credentials:AAS, QMHS
Other - Prefix:
Other - First Name:ALIVIA
Other - Middle Name:L
Other - Last Name:WEINER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2845 BELL ST
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-1720
Mailing Address - Country:US
Mailing Address - Phone:740-454-9766
Mailing Address - Fax:740-588-6452
Practice Address - Street 1:915 S RIVERSIDE DR NE
Practice Address - Street 2:
Practice Address - City:MCCONNELSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43756-9102
Practice Address - Country:US
Practice Address - Phone:740-962-5204
Practice Address - Fax:740-962-3688
Is Sole Proprietor?:No
Enumeration Date:2020-02-03
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0389216Medicaid