Provider Demographics
NPI:1609250992
Name:BROCK FAMILY THERAPY CENTER INC.
Entity Type:Organization
Organization Name:BROCK FAMILY THERAPY CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL THERAPIST/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:C
Authorized Official - Last Name:BROCK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LMFT, MBA
Authorized Official - Phone:502-785-4322
Mailing Address - Street 1:10300 BROOKRIDGE VILLAGE BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291
Mailing Address - Country:US
Mailing Address - Phone:502-785-4322
Mailing Address - Fax:502-785-4433
Practice Address - Street 1:10300 BROOKRIDGE VILLAGE BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291
Practice Address - Country:US
Practice Address - Phone:502-785-4322
Practice Address - Fax:502-785-4433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-16
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3035261QM0801X
KY0617261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100068240Medicaid
KY7100068240Medicaid