Provider Demographics
NPI:1407322589
Name:BROCK, SEIJI
Entity Type:Individual
Prefix:
First Name:SEIJI
Middle Name:
Last Name:BROCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4552 N CITRUS AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-9556
Mailing Address - Country:US
Mailing Address - Phone:208-861-0233
Mailing Address - Fax:
Practice Address - Street 1:1799 N LAKES PL
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-1833
Practice Address - Country:US
Practice Address - Phone:208-888-5905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID6970101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health