Provider Demographics
NPI:1326866864
Name:BROCK, BENNETT ALEXANDER
Entity type:Individual
Prefix:
First Name:BENNETT
Middle Name:ALEXANDER
Last Name:BROCK
Suffix:
Gender:
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:2025-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty