Provider Demographics
NPI:1104190156
Name:BROCK, MADALYN COYLE
Entity type:Individual
Prefix:
First Name:MADALYN
Middle Name:COYLE
Last Name:BROCK
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 1:143 SUGAR MILL CIR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419-9431
Mailing Address - Country:US
Mailing Address - Phone:386-965-3383
Mailing Address - Fax:
Practice Address - Street 1:848 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-7699
Practice Address - Country:US
Practice Address - Phone:407-678-8889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-07
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program