Provider Demographics
NPI:1649570128
Name:CARLILE, BROCK ADAM (MCP)
Entity Type:Individual
Prefix:MR
First Name:BROCK
Middle Name:ADAM
Last Name:CARLILE
Suffix:
Gender:M
Credentials:MCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 MARY ST
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-2027
Mailing Address - Country:US
Mailing Address - Phone:580-382-1645
Mailing Address - Fax:
Practice Address - Street 1:1920 MARY ST
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2027
Practice Address - Country:US
Practice Address - Phone:580-382-1645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-29
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4396101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor