Provider Demographics
NPI:1467989236
Name:BROCK, REBECCA (BCBA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6711 NE 182ND ST UNIT D306
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:WA
Mailing Address - Zip Code:98028-5006
Mailing Address - Country:US
Mailing Address - Phone:919-599-4570
Mailing Address - Fax:
Practice Address - Street 1:6711 NE 182ND ST UNIT D306
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:WA
Practice Address - Zip Code:98028-5006
Practice Address - Country:US
Practice Address - Phone:919-599-4570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0-17-7638106E00000X
WA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst