Provider Demographics
NPI:1033767868
Name:BROCK, MCKENZIE MARIE (MSW)
Entity Type:Individual
Prefix:MS
First Name:MCKENZIE
Middle Name:MARIE
Last Name:BROCK
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 NE MLK JR BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-3976
Mailing Address - Country:US
Mailing Address - Phone:720-515-3296
Mailing Address - Fax:
Practice Address - Street 1:1818 NE MLK JR BLVD STE C
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3976
Practice Address - Country:US
Practice Address - Phone:720-515-3296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL115051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical