Provider Demographics
NPI:1184397440
Name:MBOCK, MARCEL THIERRY
Entity type:Individual
Prefix:
First Name:MARCEL
Middle Name:THIERRY
Last Name:MBOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 NEWTON ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20018-2319
Mailing Address - Country:US
Mailing Address - Phone:202-526-1652
Mailing Address - Fax:
Practice Address - Street 1:1715 NEWTON ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-2319
Practice Address - Country:US
Practice Address - Phone:202-526-1652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-31
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDM120585792618Medicaid