Provider Demographics
NPI:1922778984
Name:KOCK, OLIVIA MARIE
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:MARIE
Last Name:KOCK
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 1:1400 LAUREL AVE APT W1002
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-1270
Mailing Address - Country:US
Mailing Address - Phone:712-579-1910
Mailing Address - Fax:
Practice Address - Street 1:3333 UNIVERSITY AVE SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-3325
Practice Address - Country:US
Practice Address - Phone:612-331-9413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-20
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician