Provider Demographics
NPI:1326866864
Name:BROCK, BENNETT ALEXANDER
Entity type:Individual
Prefix:
First Name:BENNETT
Middle Name:ALEXANDER
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:PO BOX 827
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97440-0827
Mailing Address - Country:US
Mailing Address - Phone:541-321-0872
Mailing Address - Fax:
Practice Address - Street 1:440 MAXWELL RD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404-2355
Practice Address - Country:US
Practice Address - Phone:541-321-0872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-02
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORQMHP-R-3693101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty