Provider Demographics
NPI:1114662459
Name:BROCK, MEGAN LEANN (DPT)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:LEANN
Last Name:BROCK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8851 SE 10TH AVE APT A
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-7000
Mailing Address - Country:US
Mailing Address - Phone:559-936-8602
Mailing Address - Fax:
Practice Address - Street 1:11203 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-7787
Practice Address - Country:US
Practice Address - Phone:503-698-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-02
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR63764208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation