Provider Demographics
NPI:1962730606
Name:BROCK, MARIA TONITA (LISW)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:TONITA
Last Name:BROCK
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 IRON AVE SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-3753
Mailing Address - Country:US
Mailing Address - Phone:505-908-0015
Mailing Address - Fax:
Practice Address - Street 1:1100 CARDENAS DR SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-4809
Practice Address - Country:US
Practice Address - Phone:505-266-0992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-18
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-058781041C0700X
NMCADS-012171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171100000XOther Service ProvidersAcupuncturist