Provider Demographics
NPI:1285819532
Name:BROCK, KATRINA A (LMSW)
Entity Type:Individual
Prefix:MS
First Name:KATRINA
Middle Name:A
Last Name:BROCK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:VASSAR
Mailing Address - State:MI
Mailing Address - Zip Code:48768-9584
Mailing Address - Country:US
Mailing Address - Phone:989-823-3040
Mailing Address - Fax:
Practice Address - Street 1:150 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:VASSAR
Practice Address - State:MI
Practice Address - Zip Code:48768-9584
Practice Address - Country:US
Practice Address - Phone:989-823-3040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-07
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010828281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G96288080Medicare UPIN