Provider Demographics
NPI:1407379308
Name:BROCK, MARA ELIZABETH (ATC)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:ELIZABETH
Last Name:BROCK
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:MARA
Other - Middle Name:ELIZABETH
Other - Last Name:EARL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1206 NELL ST
Mailing Address - Street 2:
Mailing Address - City:TAZEWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37879-4312
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:362 CATALPA AVE
Practice Address - Street 2:
Practice Address - City:HARROGATE
Practice Address - State:TN
Practice Address - Zip Code:37752-8149
Practice Address - Country:US
Practice Address - Phone:423-869-9923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-23
Last Update Date:2017-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20882255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer