Provider Demographics
NPI:1689848236
Name:BROCK, ROSEMARY (MFT)
Entity Type:Individual
Prefix:MS
First Name:ROSEMARY
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:MS
Other - First Name:ROMY
Other - Middle Name:
Other - Last Name:BROCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MFT
Mailing Address - Street 1:95 MONTGOMERY DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-6630
Mailing Address - Country:US
Mailing Address - Phone:707-523-8882
Mailing Address - Fax:
Practice Address - Street 1:95 MONTGOMERY DR
Practice Address - Street 2:SUITE 204
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-6630
Practice Address - Country:US
Practice Address - Phone:707-523-8882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC#42405106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist