Provider Demographics
NPI:1114358702
Name:BROCK, DERENI BLAKE (PT)
Entity Type:Individual
Prefix:MRS
First Name:DERENI
Middle Name:BLAKE
Last Name:BROCK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 COMMERCIAL DR
Mailing Address - Street 2:STE 100
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40744-5234
Mailing Address - Country:US
Mailing Address - Phone:606-657-2354
Mailing Address - Fax:
Practice Address - Street 1:195 COMMERCIAL DR
Practice Address - Street 2:STE 100
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40744-5234
Practice Address - Country:US
Practice Address - Phone:606-657-2354
Practice Address - Fax:606-657-2354
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-06
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY006310225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist