Provider Demographics
NPI:1811153042
Name:STOCK, MARY RUVEN (PHD, LCSW)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:RUVEN
Last Name:STOCK
Suffix:
Gender:F
Credentials:PHD, LCSW
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 1144
Mailing Address - Street 2:
Mailing Address - City:KILN
Mailing Address - State:MS
Mailing Address - Zip Code:39556-1144
Mailing Address - Country:US
Mailing Address - Phone:504-616-6097
Mailing Address - Fax:
Practice Address - Street 1:4423 LEISURE TIME DR # C
Practice Address - Street 2:
Practice Address - City:DIAMONDHEAD
Practice Address - State:MS
Practice Address - Zip Code:39525-3221
Practice Address - Country:US
Practice Address - Phone:504-616-6097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-07
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC29361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical