Provider Demographics
NPI:1366223604
Name:BOCK, LORRAINE MICHELLE
Entity type:Individual
Prefix:MS
First Name:LORRAINE
Middle Name:MICHELLE
Last Name:BOCK
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 1:1617 CAPALINA RD
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-1207
Mailing Address - Country:US
Mailing Address - Phone:530-957-3898
Mailing Address - Fax:
Practice Address - Street 1:1617 CAPALINA RD
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-1207
Practice Address - Country:US
Practice Address - Phone:530-957-3898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA020220815101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)