Provider Demographics
NPI:1730491895
Name:BROCK, KRISTOFER L (MS CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:KRISTOFER
Middle Name:L
Last Name:BROCK
Suffix:
Gender:M
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 W MAYFAIR AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5113
Mailing Address - Country:US
Mailing Address - Phone:209-607-3540
Mailing Address - Fax:
Practice Address - Street 1:3601 4TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79430-0002
Practice Address - Country:US
Practice Address - Phone:806-743-5660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-06
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105891235Z00000X
CA18114235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist