Provider Demographics
NPI:1912159351
Name:BROCK, DAVID J
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:J
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 1:1538 STONEY PT
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-1450
Mailing Address - Country:US
Mailing Address - Phone:517-323-8395
Mailing Address - Fax:
Practice Address - Street 1:1020 LONG BLVD
Practice Address - Street 2:5
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-6896
Practice Address - Country:US
Practice Address - Phone:517-420-6123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-16
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI63010051771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical