Provider Demographics
NPI:1114070729
Name:KOLBY, BROCK THOMAS (EDD)
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:THOMAS
Last Name:KOLBY
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1306
Mailing Address - Street 2:
Mailing Address - City:MURPHYS
Mailing Address - State:CA
Mailing Address - Zip Code:95247-1306
Mailing Address - Country:US
Mailing Address - Phone:209-728-9386
Mailing Address - Fax:
Practice Address - Street 1:2 S GREEN ST
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-4618
Practice Address - Country:US
Practice Address - Phone:209-533-6265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALPCC142101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health