Provider Demographics
NPI:1174038996
Name:BROCK, GREGG (LMFT)
Entity Type:Individual
Prefix:
First Name:GREGG
Middle Name:
Last Name:BROCK
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10990 WILSHIRE BLVD FL 8
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-3918
Mailing Address - Country:US
Mailing Address - Phone:310-400-6598
Mailing Address - Fax:
Practice Address - Street 1:21225 PACIFIC COAST HWY STE D
Practice Address - Street 2:
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90265-5276
Practice Address - Country:US
Practice Address - Phone:310-400-6598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA99329106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist