Provider Demographics
NPI:1013576198
Name:BROCK, HAYLEY KEEN (OTR/L)
Entity Type:Individual
Prefix:
First Name:HAYLEY
Middle Name:KEEN
Last Name:BROCK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5350 PINEHURST PARK DR APT 2018
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-4989
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 BLYTHE BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5812
Practice Address - Country:US
Practice Address - Phone:404-731-5911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5472225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist