Provider Demographics
NPI:1518493675
Name:BROCK, MARY ANN (MFT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:BROCK
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 OAK GROVE AVE
Mailing Address - Street 2:D202
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-4434
Mailing Address - Country:US
Mailing Address - Phone:650-380-9132
Mailing Address - Fax:
Practice Address - Street 1:825 OAK GROVE AVE
Practice Address - Street 2:D202
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-4434
Practice Address - Country:US
Practice Address - Phone:650-380-9132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC28293101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health