Provider Demographics
NPI:1508289687
Name:BROCK, IRYNA
Entity Type:Individual
Prefix:
First Name:IRYNA
Middle Name:
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 1:330 JULIA ST APT 3
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70130-3661
Mailing Address - Country:US
Mailing Address - Phone:504-442-1370
Mailing Address - Fax:
Practice Address - Street 1:330 JULIA ST. APT 3
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70130
Practice Address - Country:US
Practice Address - Phone:504-442-1370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA23633225200000X
LAA8271R225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant