Provider Demographics
NPI:1750101242
Name:MOCK, OLIVIA PAIGE (PTA)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:PAIGE
Last Name:MOCK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 222
Mailing Address - Street 2:
Mailing Address - City:PENNVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47369-0222
Mailing Address - Country:US
Mailing Address - Phone:937-489-9710
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 222
Practice Address - Street 2:
Practice Address - City:PENNVILLE
Practice Address - State:IN
Practice Address - Zip Code:47369-0222
Practice Address - Country:US
Practice Address - Phone:937-489-9710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH013616225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant