Provider Demographics
NPI:1154090009
Name:SHOCK, KRIS ELLEN (APC)
Entity type:Individual
Prefix:
First Name:KRIS
Middle Name:ELLEN
Last Name:SHOCK
Suffix:
Gender:F
Credentials:APC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 GADDIS RD NW
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-4673
Mailing Address - Country:US
Mailing Address - Phone:678-480-4275
Mailing Address - Fax:
Practice Address - Street 1:4255 WADE GREEN RD NW STE 414
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-1763
Practice Address - Country:US
Practice Address - Phone:678-213-2194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC007485101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health