Provider Demographics
NPI:1154775898
Name:BROCK, LESA
Entity type:Individual
Prefix:
First Name:LESA
Middle Name:
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 1:927 NE COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-2977
Mailing Address - Country:US
Mailing Address - Phone:816-347-3270
Mailing Address - Fax:816-524-2235
Practice Address - Street 1:927 NE COLUMBUS ST
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086-2977
Practice Address - Country:US
Practice Address - Phone:816-347-3270
Practice Address - Fax:816-524-2235
Is Sole Proprietor?:No
Enumeration Date:2016-04-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO091729163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)