Provider Demographics
NPI:1811040462
Name:BOCK, MARYANNA (LCSW)
Entity Type:Individual
Prefix:
First Name:MARYANNA
Middle Name:
Last Name:BOCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:569 BERRYS MILL RD
Mailing Address - Street 2:
Mailing Address - City:WEST BATH
Mailing Address - State:ME
Mailing Address - Zip Code:04530-6603
Mailing Address - Country:US
Mailing Address - Phone:207-443-7001
Mailing Address - Fax:
Practice Address - Street 1:569 BERRYS MILL RD
Practice Address - Street 2:
Practice Address - City:WEST BATH
Practice Address - State:ME
Practice Address - Zip Code:04530-6603
Practice Address - Country:US
Practice Address - Phone:207-443-7001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC50821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEME1265Medicare ID - Type Unspecified