Provider Demographics
NPI:1336324235
Name:BROCK, ROBERTA A (LMHC)
Entity Type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:A
Last Name:BROCK
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1948 PINEAPPLE AVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-7609
Mailing Address - Country:US
Mailing Address - Phone:321-259-7262
Mailing Address - Fax:321-259-7198
Practice Address - Street 1:2115 S BABCOCK ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-5303
Practice Address - Country:US
Practice Address - Phone:321-729-0779
Practice Address - Fax:321-729-0784
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-09
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH5549101Y00000X, 101YM0800X
FLMH9393101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor