Provider Demographics
NPI:1679078711
Name:SHROCK, AUTUMN
Entity Type:Individual
Prefix:MRS
First Name:AUTUMN
Middle Name:
Last Name:SHROCK
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 1:1704 URBAN DR
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23229-3942
Mailing Address - Country:US
Mailing Address - Phone:804-824-4405
Mailing Address - Fax:
Practice Address - Street 1:3820 NINE MILE RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-4831
Practice Address - Country:US
Practice Address - Phone:804-343-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool