Provider Demographics
NPI:1245544352
Name:MOCK, LORA D (PT)
Entity type:Individual
Prefix:
First Name:LORA
Middle Name:D
Last Name:MOCK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 BIRKDALE DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-8114
Mailing Address - Country:US
Mailing Address - Phone:217-352-6536
Mailing Address - Fax:
Practice Address - Street 1:910 BIRKDALE DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-8114
Practice Address - Country:US
Practice Address - Phone:217-352-6536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-30
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.006096225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist