Provider Demographics
NPI:1689209967
Name:O'BRIEN, BROCK
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:
Last Name:O'BRIEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18207 1ST AVE S APT C4
Mailing Address - Street 2:
Mailing Address - City:NORMANDY PARK
Mailing Address - State:WA
Mailing Address - Zip Code:98148-1851
Mailing Address - Country:US
Mailing Address - Phone:206-403-0053
Mailing Address - Fax:
Practice Address - Street 1:651 STRANDER BLVD STE 105
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98188-2914
Practice Address - Country:US
Practice Address - Phone:206-313-8840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-07
Last Update Date:2020-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB60888664106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA111524501Medicaid