Provider Demographics
NPI:1073734927
Name:BROCK, ANGELA CHRISTINA (LCSW, LMFT MBA)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:CHRISTINA
Last Name:BROCK
Suffix:
Gender:F
Credentials:LCSW, LMFT MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10300 BROOKRIDGE VILLAGE BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291
Mailing Address - Country:US
Mailing Address - Phone:502-785-4322
Mailing Address - Fax:502-785-4433
Practice Address - Street 1:10300 BROOKRIDGE VILLAGE BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291
Practice Address - Country:US
Practice Address - Phone:502-785-4322
Practice Address - Fax:502-785-4433
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0617106H00000X
KY3035104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100068240Medicaid
KY7100068240Medicaid