Provider Demographics
NPI:1235893488
Name:BROCK, LEOLA ANISSA (MA)
Entity Type:Individual
Prefix:
First Name:LEOLA
Middle Name:ANISSA
Last Name:BROCK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1789 WHITE RD
Mailing Address - Street 2:
Mailing Address - City:BONIFAY
Mailing Address - State:FL
Mailing Address - Zip Code:32425-7001
Mailing Address - Country:US
Mailing Address - Phone:850-326-2480
Mailing Address - Fax:
Practice Address - Street 1:20274 CENTRAL AVE W
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424-1957
Practice Address - Country:US
Practice Address - Phone:850-674-8888
Practice Address - Fax:850-237-1223
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-25
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health