Provider Demographics
NPI:1982922548
Name:MOCK, KATHY ANN (LCSW)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:ANN
Last Name:MOCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2520 PLEASANT RD
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-9460
Mailing Address - Country:US
Mailing Address - Phone:919-762-7857
Mailing Address - Fax:919-714-8399
Practice Address - Street 1:109 FOUNTAIN BROOK CIRCLE
Practice Address - Street 2:SUITE C
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511
Practice Address - Country:US
Practice Address - Phone:919-762-7857
Practice Address - Fax:919-714-8399
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0065891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6007501Medicaid