Basic Information
| Provider Information | |||||||||
| NPI: | 1003138744 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STOCK | ||||||||
| FirstName: | AVY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 42009 VICTORY LN | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201766269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307584515 | ||||||||
| FaxNumber: | 3307582862 | ||||||||
| Practice Location | |||||||||
| Address1: | 42009 VICTORY LN | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201766269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307584515 | ||||||||
| FaxNumber: | 3307582862 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2010 | ||||||||
| LastUpdateDate: | 02/23/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | 0810003939 | VA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
No ID Information.