Provider Demographics
NPI:1538220751
Name:KROCK, LISA A (EDD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:A
Last Name:KROCK
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:438 POND ST
Mailing Address - Street 2:
Mailing Address - City:WESTWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02090-2831
Mailing Address - Country:US
Mailing Address - Phone:781-826-8228
Mailing Address - Fax:781-826-0965
Practice Address - Street 1:24 ROCKLAND ST
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:MA
Practice Address - Zip Code:02339-2226
Practice Address - Country:US
Practice Address - Phone:781-826-8228
Practice Address - Fax:781-826-0965
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3003103T00000X, 103TF0000X, 103TA0400X, 103TA0700X, 103TC0700X, 103TC2200X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0510629Medicaid
MA0510629Medicaid