Provider Demographics
NPI:1497039648
Name:BROCK, SELINA STAR
Entity Type:Individual
Prefix:MS
First Name:SELINA
Middle Name:STAR
Last Name:BROCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3670 MAINE AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-5231
Mailing Address - Country:US
Mailing Address - Phone:626-322-7041
Mailing Address - Fax:323-263-8042
Practice Address - Street 1:942 S ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-4004
Practice Address - Country:US
Practice Address - Phone:323-263-9700
Practice Address - Fax:323-263-8042
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARW4272101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)