Provider Demographics
NPI:1275001299
Name:YOURCHOCK, MARIAH C
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:C
Last Name:YOURCHOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30755 BARRINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-1881
Mailing Address - Country:US
Mailing Address - Phone:734-552-4523
Mailing Address - Fax:
Practice Address - Street 1:6808 DEERING ST
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:MI
Practice Address - Zip Code:48135-2246
Practice Address - Country:US
Practice Address - Phone:847-306-9843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-07
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI7401001472103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty