Provider Demographics
NPI:1689937724
Name:BROCK, CARY GLEN (QMHP)
Entity Type:Individual
Prefix:MR
First Name:CARY
Middle Name:GLEN
Last Name:BROCK
Suffix:
Gender:M
Credentials:QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 W COLUMBIA LN
Mailing Address - Street 2:
Mailing Address - City:IRRIGON
Mailing Address - State:OR
Mailing Address - Zip Code:97844-6900
Mailing Address - Country:US
Mailing Address - Phone:541-701-4863
Mailing Address - Fax:
Practice Address - Street 1:155 W COLUMBIA LN
Practice Address - Street 2:
Practice Address - City:IRRIGON
Practice Address - State:OR
Practice Address - Zip Code:97844-6900
Practice Address - Country:US
Practice Address - Phone:541-701-4863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-22
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health