Provider Demographics
NPI:1508232372
Name:DEBROCK, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:DEBROCK
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 1:510 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-6744
Mailing Address - Country:US
Mailing Address - Phone:614-257-8363
Mailing Address - Fax:
Practice Address - Street 1:510 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-6744
Practice Address - Country:US
Practice Address - Phone:614-257-8363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-17
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency