Provider Demographics
NPI:1154786812
Name:BROCK, KEITH DUANE
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:DUANE
Last Name:BROCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2237 S MCFEE AVENUE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85713
Mailing Address - Country:US
Mailing Address - Phone:817-681-3776
Mailing Address - Fax:
Practice Address - Street 1:7426 S CAMINO VAHCOM
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85757
Practice Address - Country:US
Practice Address - Phone:520-879-5693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-23
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-11831101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)