Provider Demographics
NPI:1619205366
Name:SHOCK, JAMES JOSEPH III (BA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:JOSEPH
Last Name:SHOCK
Suffix:III
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 LAIRD STREET
Mailing Address - Street 2:REAR
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702
Mailing Address - Country:US
Mailing Address - Phone:570-408-9320
Mailing Address - Fax:570-408-9324
Practice Address - Street 1:307 LAIRD STREET
Practice Address - Street 2:REAR
Practice Address - City:WILKES-BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702
Practice Address - Country:US
Practice Address - Phone:570-408-9320
Practice Address - Fax:570-408-9324
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-18
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)