Provider Demographics
NPI:1437793163
Name:BROCK, MARTY JACOB (DPT)
Entity Type:Individual
Prefix:
First Name:MARTY
Middle Name:JACOB
Last Name:BROCK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 DEER RDG
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-8713
Mailing Address - Country:US
Mailing Address - Phone:601-543-9018
Mailing Address - Fax:
Practice Address - Street 1:7 RIVERS DR STE 10&20
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-1323
Practice Address - Country:US
Practice Address - Phone:601-909-5006
Practice Address - Fax:601-909-5008
Is Sole Proprietor?:No
Enumeration Date:2019-11-06
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT6673225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist