Provider Demographics
NPI:1255482543
Name:SCHROCK, KEVIN J (O T)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:SCHROCK
Suffix:
Gender:M
Credentials:O T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 W WASHINGTON ST STE 230
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-2560
Mailing Address - Country:US
Mailing Address - Phone:309-347-5579
Mailing Address - Fax:309-347-4264
Practice Address - Street 1:111 W WASHINGTON ST STE 230
Practice Address - Street 2:
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-2560
Practice Address - Country:US
Practice Address - Phone:309-347-5579
Practice Address - Fax:309-347-4264
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2024-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056005963225X00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01030410OtherRR MEDICARE
IL537460033Medicare PIN