Provider Demographics
NPI:1841842564
Name:MOCK, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 AMBUSH ST APT 310
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23693-5679
Mailing Address - Country:US
Mailing Address - Phone:631-901-3711
Mailing Address - Fax:
Practice Address - Street 1:100 AMBUSH ST APT 310
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:VA
Practice Address - Zip Code:23693-5679
Practice Address - Country:US
Practice Address - Phone:631-901-3711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-12
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133001454103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
1528793189OtherTRICARE