Provider Demographics
NPI:1760043368
Name:BROCK, MACI
Entity Type:Individual
Prefix:
First Name:MACI
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 358
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:OR
Mailing Address - Zip Code:97495-0358
Mailing Address - Country:US
Mailing Address - Phone:541-530-2520
Mailing Address - Fax:
Practice Address - Street 1:940 NW GARDEN VALLEY BLVD STE 104
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2098
Practice Address - Country:US
Practice Address - Phone:541-378-4104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician