Provider Demographics
NPI:1679041636
Name:BROCK, MELISSA MARIE
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:BROCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:MARIE
Other - Last Name:AMMERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1931 ERIN AVE
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91784-1545
Mailing Address - Country:US
Mailing Address - Phone:909-771-8852
Mailing Address - Fax:
Practice Address - Street 1:679 S NEW HAMPSHIRE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90005-1355
Practice Address - Country:US
Practice Address - Phone:626-254-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA41003167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator