Provider Demographics
NPI:1386176592
Name:BROCK, CHARLOTTE (COTA/L)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3953 WEBER WAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40514-1009
Mailing Address - Country:US
Mailing Address - Phone:859-202-1316
Mailing Address - Fax:
Practice Address - Street 1:2701 CHESTNUT STATION CT
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-6395
Practice Address - Country:US
Practice Address - Phone:800-335-1060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY170593224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant