Provider Demographics
NPI:1689168247
Name:SHROCK, LEAH
Entity Type:Individual
Prefix:
First Name:LEAH
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 1:340 S LEMON AVE # 9892
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-2706
Mailing Address - Country:US
Mailing Address - Phone:415-403-2156
Mailing Address - Fax:
Practice Address - Street 1:340 S LEMON AVE # 9892
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:CA
Practice Address - Zip Code:91789-2706
Practice Address - Country:US
Practice Address - Phone:415-403-2156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0967041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical