Provider Demographics
NPI:1558068569
Name:MOCK, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:MOCK
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:PO BOX 1242
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30459-1242
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27 S MAIN ST
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5245
Practice Address - Country:US
Practice Address - Phone:912-225-3769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional