Provider Demographics
NPI:1194819102
Name:SCHOCK, KATHLEEN DIANE (MS)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:DIANE
Last Name:SCHOCK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 JASMINE CIR
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06461-1789
Mailing Address - Country:US
Mailing Address - Phone:203-882-1457
Mailing Address - Fax:
Practice Address - Street 1:103 JASMINE CIR
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06461-1789
Practice Address - Country:US
Practice Address - Phone:203-882-1457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000723101YA0400X
CT001435101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008038045Medicaid
CT004041000Medicaid
CT008038045Medicaid