Provider Demographics
NPI:1114322005
Name:BROCK, AMANDA (MS BCBA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:MS BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3002 LINCOLN DR W
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-1527
Mailing Address - Country:US
Mailing Address - Phone:856-810-7599
Mailing Address - Fax:
Practice Address - Street 1:3002 LINCOLN DR W
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-1527
Practice Address - Country:US
Practice Address - Phone:856-810-7599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1-14-15161103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst