Provider Demographics
NPI:1558624312
Name:KOCK, TRACEY E (ITDS)
Entity Type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:E
Last Name:KOCK
Suffix:
Gender:F
Credentials:ITDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21113 LAKE TALIA BLVD
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34638-3738
Mailing Address - Country:US
Mailing Address - Phone:813-873-1936
Mailing Address - Fax:813-873-8837
Practice Address - Street 1:21113 LAKE TALIA BLVD
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34638-3738
Practice Address - Country:US
Practice Address - Phone:813-873-1936
Practice Address - Fax:813-873-8837
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC007369104100000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker