Provider Demographics
NPI:1639738719
Name:BROCK, NICHOLAS COLBY (OTR/L)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:COLBY
Last Name:BROCK
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 CENTRAL ISLAND ST UNIT 459
Mailing Address - Street 2:
Mailing Address - City:DANIEL ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29492-6806
Mailing Address - Country:US
Mailing Address - Phone:703-987-7283
Mailing Address - Fax:
Practice Address - Street 1:4015 2ND AVE STE B
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486-7882
Practice Address - Country:US
Practice Address - Phone:843-376-3996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5558225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist