Provider Demographics
NPI:1104409077
Name:BROCK, BERKLEY LAUREL
Entity type:Individual
Prefix:
First Name:BERKLEY
Middle Name:LAUREL
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 1:1059 WESTBURY DR
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36609-3337
Mailing Address - Country:US
Mailing Address - Phone:205-566-5859
Mailing Address - Fax:
Practice Address - Street 1:7125 HITT RD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36695-4431
Practice Address - Country:US
Practice Address - Phone:251-422-1827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-29
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst