Provider Demographics
NPI:1275879223
Name:MOCK, DENICE (LCSW)
Entity Type:Individual
Prefix:
First Name:DENICE
Middle Name:
Last Name:MOCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-4410
Mailing Address - Country:US
Mailing Address - Phone:815-758-1358
Mailing Address - Fax:
Practice Address - Street 1:93 W GENEVA ST
Practice Address - Street 2:
Practice Address - City:WILLIAMS BAY
Practice Address - State:WI
Practice Address - Zip Code:53191-9562
Practice Address - Country:US
Practice Address - Phone:262-607-6390
Practice Address - Fax:262-627-6387
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-19
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0134571041C0700X, 1041C0700X
WI9266-1231041C0700X
102L00000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
No104100000XBehavioral Health & Social Service ProvidersSocial Worker